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Year : 2018  |  Volume : 62  |  Issue : 1  |  Page : 79-80  

Subcutaneous emphysema - An unexpected cause for respiratory distress during vitreoretinal surgery under peribulbar block


Department of Anaesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, India

Date of Web Publication12-Jan-2018

Correspondence Address:
Dr. Kanil Ranjith Kumar
Department of Anaesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, Room No 5011, New Delhi - 110 029
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ija.IJA_606_17

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How to cite this article:
Sinha R, Kumar KR, Selvam V, Chowdhury AR. Subcutaneous emphysema - An unexpected cause for respiratory distress during vitreoretinal surgery under peribulbar block. Indian J Anaesth 2018;62:79-80

How to cite this URL:
Sinha R, Kumar KR, Selvam V, Chowdhury AR. Subcutaneous emphysema - An unexpected cause for respiratory distress during vitreoretinal surgery under peribulbar block. Indian J Anaesth [serial online] 2018 [cited 2019 Sep 15];62:79-80. Available from: http://www.ijaweb.org/text.asp?2018/62/1/79/223076



Sir,

In our country, ophthalmic blocks are usually performed by the operating surgeon. However, in cases of complications, the anaesthesiologist is called for management of the emergency situation. Here, we report an unexpected respiratory complication following globe perforation during peribulbar block.

A 65-year-old-male with cataract and vitreous haemorrhage in the left eye was scheduled for phacoemulsion and vitrectomy under peribulbar block. He had no other co-morbid illness. After attaching monitors (electrocardiogram, non-invasive blood pressure and pulse-oximetery probe), the ophthalmic resident performed left eye peribulbar block with 5 ml 2% lignocaine and 5 ml 0.5% bupivacaine at inferotemporal and medial region.

After air-fluid exchange in vitrectomy, the patient complained of respiratory discomfort and upper chest pain. The attending anaesthesiologist noticed that the patient's heart rate was 100/min, respiratory rate around 20/min with blood pressure 130/85 mmHg and 97% saturation. On lifting the drapes, there was puffiness of face, swelling over the left eye, neck and upper chest [Figure 1]. Palpation revealed crepitus over subcutaneous tissue. On auscultation, air entry was equal on both sides and except for the subcutaneous crepitation, there was no other added sound. A provisional diagnosis of subcutaneous emphysema was made but the cause for the emphysema was not evident at that time. Respiratory symptoms resolved after propped up position and supplemental oxygen for 2 h. An urgent chest X-ray was done to rule out pneumothorax and pneumomediastinum. The patient was monitored in the post-anaesthesia care unit for 24 h during which otorhinolaryngologist and pulmonary medicine consultations were done.
Figure 1: Patient with face and neck swelling due to subcutaneous emphysema

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Subcutaneous emphysema leading to respiratory distress during vitrectomy is rare and unanticipated. Surgical emphysema has been reported after orbital floor fracture, tracheobronchial or lung injury. Other mechanisms include accidental injection of compressed gas into subcutaneous tissue. There have been previous reports of subcutaneous emphysema following dental and endoscopic surgeries where compressed gases were used.[1] Colson et al. had also reported subcutaneous emphysema and pneumomediastinum during vitreoretinal surgery.[2] They proposed that excessive infusion pressure due to equipment malfunction had forced pressurized gas to sweep through microlacerations in the retina and through the puncture site of retrobulbar block. However, in our case, the infusion pressures were maintained between 25 and 30 mmHg only.

While looking for the possible causes for subcutaneous emphysema in our case, the operating surgeon revealed that he had noticed a small, apparently insignificant retinal perforation in the inferonasal region. Although less common, globe perforation is a well-known complication of peribulbar bock.[3] Extravasation of pressurized air and fluid through the unrecognized globe perforation due to peribulbar block explains the cause for subcutaneous emphysema in our case. Asnani et al. had reported subcutaneous emphysema following vitreo-retinal surgery in a perforated globe.[4] They postulated that the needle tract through sclera, orbital septum, subcutaneous tissue and skin could have provided the path of least resistance for the air-fluid to escape. Even though our patient made an uneventful recovery, compression optic neuropathy, central retinal artery compression, pneumomediastinum and airway obstruction are the ocular and life-threatening complications of subcutaneous emphysema.

To conclude unrecognized globe perforation might present as subcutaneous emphysema during vitreoretinal surgery. Early detection and appropriate treatment would prevent life-threatening complications.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
McKenzie WS, Rosenberg M. Iatrogenic subcutaneous emphysema of dental and surgical origin: A literature review. J Oral Maxillofac Surg 2009;67:1265-8.  Back to cited text no. 1
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2.
Colson JD. Cervicofacial subcutaneous emphysema and pneumomediastinum after retinal detachment surgery: Just another monitored anesthesia eye case. J Clin Anesth 2011;23:410-3.  Back to cited text no. 2
    
3.
Ball JL, Woon WH, Smith S. Globe perforation by the second peribulbar injection. Eye (Lond) 2002;16:663-5.  Back to cited text no. 3
    
4.
Asnani HT, Mehta VC, Nair AG, Jain V. Bilateral periorbital and cervicofacial emphysema following retinal surgery and fluid gas exchange in a case of inadvertent globe perforation. Indian J Ophthalmol 2015;63:541-2.  Back to cited text no. 4
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