|Year : 2008 | Volume
| Issue : 6 | Page : 849
Anaesthetic Considerations in A Child with Bilateral Hydatid Cysts of Lung
Harsimran Singh1, Harjinder Kohli1, Anju Grewal2, Sushil Budhiraja3
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 Acceptance||26-Aug-2008|
|Date of Web Publication||19-Mar-2010|
Dept of Anaesthesiology and Resuscitation, Dayanand Medical College and Hospital, Ludhiana. Punjab-141001
Source of Support: None, Conflict of Interest: None
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|| |
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. ,, 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. , 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  and its anaesthetic management is a challenge to anaesthesiologist.
| Case report|| |
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|| |
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. 
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.  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. , 
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  . 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. 
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.  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. 
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  . 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  .
Intraoperative rupture of the cysts can cause serious anaphylactic reactions and prophylaxis against anaphylaxis is recommended  . 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|| |
|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. [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. |
|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. |
|4.||Kir A, Baran E. Simultaneous operation for hydatid cyst of right lung and liver. Thorac Cardiovasc Surgeon 1995; 43: 62-4. |
|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. |
|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. |
|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. |
|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. |
|9.||Saidi F, Rezvan-Nobahar M. Intraoperative bronchial aspiration of ruptured pulmonary hydatid cysts. Ann Thorac Surg 1990; 50:631-6. [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. |
|11.||Rowe R, Andropoulos D, Heard M, et al. Anesthestic management of pediatric patients undergoing thoracoscopy. J Cardiothorac Vasc Anesth 1994; 8: 563-566. [PUBMED] [FULLTEXT] |
|12.||Gregory B Hammer. Differential lung ventilation in infants and children with pulmonary hyperinflation. Pediatric Anesthesia 2003;13: 373-4. |
|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. |
|14.||Dave N, Halbe AR, Kadam PP, et. al. Bilateral pulmonary hydatid cysts in a child: anesthetic management. Pediatric Anesthesia 2004;14: 889-892. |
|15.||Sola JL, Vaquerizo MJ. Intraoperative anaphylaxis caused by a hydatid cyst. Acta Anesthesiol Scand 1995; 39: 273-274. |
[Figure 1], [Figure 2], [Figure 3]