Subcutaneous emphysema

[stonemd]

90yo had R total shoulder GA + ISB cath, uneventful course and cath removal. Now 5 days later patient presents to ER with increasing R chest/ shoulder pain and SQ emphysema over right chest! Vital signs normal, CTA and CXR no pneumo, no fever, nl WBC. Where did the air come from?

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[Ignatius J]

90yo had R total shoulder GA + ISB cath, uneventful course and cath removal. Now 5 days later patient presents to ER with increasing R chest/ shoulder pain and SQ emphysema over right chest! Vital signs normal, CTA and CXR no pneumo, no fever, nl WBC. Where did the air come from?

Weird. One of those cases where I could try and just BS something that may or may not sound intelligent, or just say that no pneumo on CXR and uncomplicated block means it wasn't me and skiddattle.

 

[Planktonmd]

90yo had R total shoulder GA + ISB cath, uneventful course and cath removal. Now 5 days later patient presents to ER with increasing R chest/ shoulder pain and SQ emphysema over right chest! Vital signs normal, CTA and CXR no pneumo, no fever, nl WBC. Where did the air come from?

Is he febrile or septic?
I would be concerned about a gas forming infection and gangrene.

 

[Wiscoblue]

Maybe be he popped a bleb while coughing in the postop period.

Obviously the other cause would be a needle to the lung but it just took a while to develop the pneumo. Maybe he was breathing spontaneously during surgery? There doesn't have to be a big pneumo on X-ray.

Someone injected air into the catheter?

 

[stonemd]

Prob not infection with no fever, no leukocytosis, no drainage from wound.

Doubt air via cath

No pneumo currently

Does spont or procedural pneumo resolve completely before appearance of sq air?

How often does pneumothorax result in sq air?

Patient does have a pacemaker under right clavicle

Any possibility of a para tracheal cyst that might have been perforated?

 

[Foodie]

POD #5 with singular presentation of right-sided subcutaneous emphysema without PTX on CT is puzzling. I would confirm that gas gangrene is ruled out for sure. Did you do the block yourself to be certain that you were nowhere near the lung with both needle + catheter? Also consider the possibility of catheter migrating between fascial planes periop -> air tracking.

Yeah, paratracheal air cyst rupture is a possibility, but clinical presentation would have occurred earlier than 5 days postop if due to needle perforation. You'd need a preop cervical CT to compare.

 

[Consigliere]

You did the block, therefore all blame will be placed on you.

 

[amyl]

I'd guess bleb. Was he a copder? Just bc u can't see a pneumo now doesn't mean there isn't/wasn't a small one. I agree you will likely be blamed. Known possible complication.

 

[stonemd]

I did not do the block. Done by experienced doc but he did say first placement was not optimal so it was repeated preop to insure good postop analgesia.

 

[stonemd]

Old CT should right apical scarring, CXR hyperinflation, emphysema

 

[epidural man]

was the surgery done with scope or open?

 

[Planktonmd]

I'd guess bleb. Was he a copder? Just bc u can't see a pneumo now doesn't mean there isn't/wasn't a small one. I agree you will likely be blamed. Known possible complication.

How does a pulmonary bleb produce subcutaneous emphysema without pneumothorax???

 

[Planktonmd]

I am going to guess that the patient is aspirating air into the subcutaneous tissue through the hole around the interscalene catheter.
Someone poked a big hole with a Tuhoy and it's allowing air entrapment every time the patient takes a deep breath.
Take the catheter out and apply an occlusive dressing.

 

[stonemd]

Was open procedure, pos pressure vent

How often is a needle or spontaneous pneumothorax associated with sq air?

Is apical bleb puncture associated with sq air?

Can air really be entrained from ISB puncture site with spontaneous ventilation?

 

[Wiscoblue]

Air cannot be entrained. Negative pressure during respiration is only intrathoracic.
Inter scalene catheter cannot suck air.

Pneumothorax can be associated with subcutaneous air if the patient has copd and is breathing hard and developing positive pressure in the pleural space during expiratory phase.


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[epidural man]

Interesting case. Write it up.

 

[cleansocks]

how was the intubation? bougie used?

 

[Planktonmd]

Air cannot be entrained. Negative pressure during respiration is only intrathoracic.
Inter scalene catheter cannot suck air.

Pneumothorax can be associated with subcutaneous air if the patient has copd and is breathing hard and developing positive pressure in the pleural space during expiratory phase.


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You don't know where that catheter is, you don't know the pressure within the neck fascial layers during deep breathing, and you don't know how big a of a hole or how traumatic this block was.
But all that said, a small tracheal tear during intubation is more likely the cause here.

 

[amyl]

No pneumo on chest X-ray 5 days later doesn't mean that there wasn't originally a small sub clinical pneumo or that there still isn't. You can't always see a small pneumo on cxr

 

[stonemd]

Finally rad calls possible small r pneumo. No signif improvement of sq air. My gut feeling is that this was a pneumo spont or due to ppv. Perhaps pacer or apical scarring made sq air more likely.