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CASE REPORT
Year : 2008  |  Volume : 52  |  Issue : 6  |  Page : 849 Table of Contents     

Anaesthetic Considerations in A Child with Bilateral Hydatid Cysts of Lung


1 Senior Resident, Dept of Pediatric Surgery, Dayanand Medical College and Hospital, Ludhiana. Punjab, India
2 Associate Professor, Deptt of Anaesthesiology, Dayanand Medical College and Hospital, Ludhiana. Punjab, India
3 Professor, Dept of Pediatric Surgery, Dayanand Medical College and Hospital, Ludhiana. Punjab, India

Date of Acceptance26-Aug-2008
Date of Web Publication19-Mar-2010

Correspondence Address:
Harsimran Singh
Dept of Anaesthesiology and Resuscitation, Dayanand Medical College and Hospital, Ludhiana. Punjab-141001
India
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Source of Support: None, Conflict of Interest: None


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Bilateral hydatid cyst of lung in a child is a challenge to anaesthesiologist. The benefits of one lung versus two lung ventilation is still a question. A 9-yr-old male child presented with respiratory distress. The chest X-ray showed the presence of two cysts bilaterally in the lung fields. A possibility of bilateral hydatid cyst in lung was considered. The child was taken up for emergency single stage bilateral thoracotomy under general anaesthesia. Two lung ventilation technique was used. Postoperatively the child was kept on controlled ventilation in the paediatric intensive care unit. The child was weaned off from ventilatory support and extubated 48 hours after the surgery.

Keywords: Bilateral hydatid cyst, Two lung ventilation


How to cite this article:
Singh H, Kohli H, Grewal A, Budhiraja S. Anaesthetic Considerations in A Child with Bilateral Hydatid Cysts of Lung. Indian J Anaesth 2008;52:849

How to cite this URL:
Singh H, Kohli H, Grewal A, Budhiraja S. Anaesthetic Considerations in A Child with Bilateral Hydatid Cysts of Lung. Indian J Anaesth [serial online] 2008 [cited 2020 Jan 29];52:849. Available from: http://www.ijaweb.org/text.asp?2008/52/6/849/60700


   Introduction Top


Hydatid disease (Echinococcus granulosus) is endemic in the Middle East as well as other parts of the world, including India, Africa, South America, New Zealand, Australia, Turkey and Southern Europe. [1],[2],[3] In­festation by hydatid disease in humans most commonly occurs in the liver (55-70%) followed by the lung (18­-35%); the two organs can be affected simultaneously in about 5-13% of cases. [4],[5] Even though hydatid cysts can occur in any organ, it is rare to see the disease involving both the lungs simultaneously. A single stage bilateral thoracotomy is a suitable surgical method for treating bilateral pulmonary hydatid cysts [6] and its an­aesthetic management is a challenge to anaesthesiologist.


   Case report Top


A 9-year-old male child weighing 20 kg presented to the emergency department with a history of fever and cough for 2 months. Fever was mild to moderate, intermittent, without any diurnal variation, and the cough was non purulent. Since last 7 days the child had a history of gradually progressive respiratory distress. The child was already investigated outside and the chest X ray (done prior to admission) showed two homogenous cysts in both the lung fields [Figure 1]. Ultrasound guided drainage of the left cyst was tried at the referring centre from which clear fluid was aspirated. The post interven­tion X ray showed a large cyst on the right side, the lining of the cyst on the left side and the presence of the hydro­pneumothorax on the left side which may have devel­oped after intervention [Figure 2]. The mediastinum includ­ing the trachea was shifted to the right side. The child was referred to our hospital for further management.

On examination the child was restless and irri­table. The child had a pulse rate of 140/min, respira­tory rate of 42/min. The blood pressure was 100/70 mm of Hg , temp 99.6 °F & SpO 2 97% on room air.

On the basis of the above findings a differential diagnosis of a hydatid cyst with a lower possibility of bronchogenic cyst was kept. A CT scan of the chest showed the similar findings as depicted in the X ray [Figure 3]. The child was shifted to operation theatre for further management.

In the view of planned bilateral thoracotomy, an informed high risk consent was taken and arrangements made for postoperative ventilation.

The patient was premedicated with 0.3 mg midazolam and 0.1 mg glycopyrrolate intravenously. Induction was achieved with 20µg fentanyl, 40 mg ketamine and 10 mg atracurium. A successful and atraumatic intubation was carried out with a 5.5 mm internal diameter cuffed endotracheal tube. Continu­ous ECG, non invasive blood pressure (NIBP), central venous pressure (CVP), oxygen saturation (SpO 2 ) and end tidal CO 2 (EtCO 2 ) were monitored. Ventilation was performed with intermittent positive pressure (IPPV) at a rate of 14-16 breaths per minute using a combina­tion of oxygen, nitrous oxide(40:60) and halothane, with a tidal volume of 250 ml and a peak airway pressure (Paw) of 22 cm H 2 O. The patient also received titrated doses of atracurium and fentanyl every half hourly.

The patient was positioned in the left lateral posi­tion first and right posterolateral thoracotomy was per­formed. Twenty minutes prior to the excision of the cyst hydrocortisone 100 mg i.v. and pheniramine i.v. were given slowly. Hydatid cysts were removed, bronchial leaks were sutured and dead spaces were obliterated. Chest was closed with water seal drain.

Similarly the left posterolateral thoracotomy was done in right lateral position.

After the completion of the procedure the child was kept intubated to be kept for controlled ventilation for at least 24 hours and was shifted to the paediatric intensive care unit of the hospital.

Post operative course was uneventful. The child was extubated after 30 hrs of surgery. Analgesia was given in the form of morphine 1mg every 6 hourly. The child was allowed orally after 72 hrs and was shifted to the ward after accepting orally. The child was dis­charged in a satisfactory condition after ten days and called for follow up after 7 days.


   Discussion Top


Single stage bilateral thoracotomy for hydatid cyst in a child is a once in a life time surgery. The lack of literature leaves a dilemma whether to use two lung or one ventilation in this scenario.

In patients undergoing surgical excision of pulmo­nary hydatid cyst, the healthy lung must be isolated in order to protect it against transbronchial spread of hy­datid fluid should inadvertent rupture of the cyst occurs during its dissection and exposure. [7]

In case of bilateral cyst in the lungs there arises a problem as no lung can be labeled as healthy. More­over single lung ventilation of the non operative side can lead to various complications including atelectasis, hypoxemia, rupturing of the cyst and opening of the bronchial leaks once they have been repaired after re­moving the cyst. [8] In adults the use of double lumen tube during pulmonary hydatid surgery has solved the prob­lem of isolating the two lungs as it is possible to control ventilation and prevent flooding of the contralateral lung in case of rupture. [9], [10]

In paediatric patients, single lung ventilation (SLV) may be performed by advancing a tracheal tube (TT) into the main stem bronchus opposite the side of sur­gery, after which the non ventilated lung will deflate because of absorption atelectasis [11] . Problems can oc­cur, however, when this technique is used. If a smaller, uncuffed TT is used, it may be difficult to provide an adequate seal of the intubated bronchus. This may pre­vent the operative lung from adequately collapsing. In patients with unilateral lung infection, this may fail to protect the healthy, ventilated lung from contamination by purulent material from the contralateral lung. [12]

Whether a cuffed or uncuffed TT is used, the op­erative lung cannot be suctioned with this technique. Hypoxemia may occur because of obstruction of the upper lobe bronchus, especially when the short right main stem bronchus is intubated. [12] When this technique is used, the contralateral lung is neither ventilated nor oxygenated. Accordingly, significant oxygen desaturation may occur because of persistent perfu­sion of atelectatic lung units. [12]

Alternatively, a balloon-tipped endobronchial catheter may be used for bronchial blockade and SLV. When closed tip bronchial blockers are used, the op­erative lung cannot be suctioned and oxygen and con­tinuous positive airway pressure cannot be provided to the operative lung. Therefore, some practitioners pre­fer to use a balloon-tipped, end-hole catheter for SLV. This type of catheter may be inserted into the mainstem or segmental bronchus and allows for administration of suction, oxygen and continuous airway pressure through the catheter lumen [13] . The latter allows oxygen delivery to perfused alveoli, resulting in reduced intrapulmonary shunting and improved oxygenation.

Single lung ventilation has been advocated to pro­tect the healthy lung, but we proceeded with two-lung ventilation as our patient had bilateral cysts. Advancing a tracheal tube into the mainstem bronchus opposite the side of surgery, was not used as it may fail to pro­vide any protection to the contralateral lung against transbronchial spread of hydatid fluid should inadvert­ent rupture of the cyst occurs. It would also have im­paired ability to do suction on the operative side.

One lung ventilation by this method had signifi­cant chances of rupture of the cyst on the ventilated side and opening of the freshly closed bronchial leaks since we were planning a single stage bilateral thorac­otomy.

Considering all the above advantages and disad­vantages of one lung ventilation in this peculiar situation it was decided to proceed with two lung ventilation.

Nandini Dave et al have also advocated the use of two lung ventilation in a child with bilateral hydatid cyst even though they did it in a two stage procedure after a gap of 10 days. Although one lung ventilation is recommended for cystic lesions of the lung, in case of bilateral lesions conventional two-lung ventilation would be safer in view of possible rupture of the cyst on the ventilated side [14] .

Intraoperative rupture of the cysts can cause se­rious anaphylactic reactions and prophylaxis against anaphylaxis is recommended [15] . It assumes immense importance especially in a bilateral cyst in a paediatric patient where a lung isolation technique has not been used.

Hydatid cyst involvement in children in lungs has a different pattern than adults. One stage bilateral tho­racotomy is a suitable surgical method for treating bi­lateral pulmonary hydatid cysts. We used two lung ven­tilation in this patient successfully without any compli­cations or adverse effects. Prophylactic hydrocortisone also has immense role in such a setting.

 
   References Top

1.Goel MC, Agarwal MR, Misra A. Percutaneous drain­age of renal hydatid cyst: early results and follow-up. Br J Urol 1995; 75: 724-8.  Back to cited text no. 1  [PUBMED]    
2.Altinors N, Senveli E, Donmez T, Bavbek M, Kars Z, Sanli M. Management of problematic intracranial hy­datid cysts. Infection 1995; 23: 283-7.  Back to cited text no. 2      
3.Brown RA, Millar AIW, Steiner Z, Krige JEJ, Burkimsher D, Cywes S. Hydatid cyst of the pancreas: a case report in a child. Eur J Pediatr Surg 1995; 5:121-4.  Back to cited text no. 3      
4.Kir A, Baran E. Simultaneous operation for hydatid cyst of right lung and liver. Thorac Cardiovasc Surgeon 1995; 43: 62-4.  Back to cited text no. 4      
5.Guntz M, Coppo B, Lorimier G, Cronier P. Hydatid cyst of the liver appearing late (10-22 years) after surgical treatment of pulmonary hydatidosis. Physiopathologic problems J Chir 1990;127:375-81.  Back to cited text no. 5      
6.Biswas B, Ghosh D, Bhattacharjee R, et al. One stage bilateral thoracotomy for hydatid cysts of both lung. Ind J Thorac Cardiovasc Surg 2004;20: 126-128.  Back to cited text no. 6      
7.Baraka A, Slim M, Dajani . One lung ventilation of chil­dren during surgical excision of hydatid cysts of the lung . Br J Anaesth 1982;54:523-27.  Back to cited text no. 7      
8.Hidir Esme, Huseyin Fidan, Ahmet Cekirdekci. The prob­lems and advantages of one lung ventilation during surgical intervention in pulmonary hydatid cyst disease. Ind J Thorac Cardiovasc Surg 2006; 22: 137-140.  Back to cited text no. 8      
9.Saidi F, Rezvan-Nobahar M. Intraoperative bronchial aspiration of ruptured pulmonary hydatid cysts. Ann Thorac Surg 1990; 50:631-6.  Back to cited text no. 9  [PUBMED]    
10.Salih OK, TopgcuogluMS, Celic SK, et al. Surgical treat­ment of hydatid cysts of the lung: analysis of 405 pa­tients. Can J Surg 1998;41:131-5.  Back to cited text no. 10      
11.Rowe R, Andropoulos D, Heard M, et al. Anesthestic management of pediatric patients undergoing thoracos­copy. J Cardiothorac Vasc Anesth 1994; 8: 563-566.  Back to cited text no. 11  [PUBMED]  [FULLTEXT]  
12.Gregory B Hammer. Differential lung ventilation in in­fants and children with pulmonary hyperinflation. Pedi­atric Anesthesia 2003;13: 373-4.  Back to cited text no. 12      
13.Boujokous AJ, Keenan RJ. Use of bronchial blocker to improve gas exchange in respiratory failure and differ­ential lung disease. Chest 1996; 110: 1110-1111.  Back to cited text no. 13      
14.Dave N, Halbe AR, Kadam PP, et. al. Bilateral pulmonary hydatid cysts in a child: anesthetic management. Pedi­atric Anesthesia 2004;14: 889-892.  Back to cited text no. 14      
15.Sola JL, Vaquerizo MJ. Intraoperative anaphylaxis caused by a hydatid cyst. Acta Anesthesiol Scand 1995; 39: 273-274.  Back to cited text no. 15      


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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