Tension PTX

[CodeBlu]

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You've done a bowel case for a perfed DU in an otherwise young healthy guy who took too much naproxen...

At the end of the case, you put in a triple lumen with ultrasound, but still manage to get a little hole in the pleura...

Patient extubated and in PACU, develops shortness of breath... can anyone walk me through the physiology of how this patient could develop a tension PTX if he's spontaneously breathing and not positive pressure ventilated... ?

Spontaneously breathing patients get tension pneumothoraces | Thorax

 

[T-burglar]

Some kind of communication that only admits air to the pleura during inspiration and prevents it escaping on expiration. A pathology that acts as a one way valve.

I can see how a young and strong patient with severe dyspnea would vigorously inhale and create significant negative pleural pressure in inspiration but when exhaling the opening that was admitting air to the pleura closes.

 

[AnesRunner]

The problem isn't the hole in the pleura. It's a hole in the parenchyma leading a small bronchopleural fistula and entrainment of air in the pleural space. You don't need positive pressure to lead to a tension PTX. Air goes into the pleural space and cannot exit. One-way valve effect like T-burglar mentioned.

 

[Arch Guillotti]

Why are you putting a triple lumen in a healthy patient?

 

[Ronin786]

Why are you putting a triple lumen in a healthy patient?

Vasopressors?

 

[deleted697127]

Is this your case? Was it laparoscopic? What type of imaging was there preop? A quick lit search shows a few case reports of pneumothorax as a rare presenting sign of perforated diverticulitis. Could a small pneumothorax have been there and expanded during the case with laparoscopy or positive pressure leading to hypotension and need for pressors and triple lumen?

Aside from the pneumothorax in pacu, was there something during the placement that made you think you may have put a hole in the pleura?

 

[dhb]

Vasopressors?

A big Kahuna burger on line two and a tasty beverage on line 3.

 

[Noyac]

What location was the CVL placed?

 

[deleted162650]

What location was the CVL placed?

The lung

 

[Noyac]

The lung

Perfect placement. Good thing US was available for this.

 

[deleted171991]

What location was the CVL placed?

My money is on subclavian.

 

[deleted875186]

My money is on subclavian.

I think statistically the IJ is a higher rate of PTX.

 

[CodeBlu]

Right IJ. Yes for pressors.

 

[narcotics999]

I think statistically the IJ is a higher rate of PTX.

Before or after the use of Ultrasound?

 

[narcotics999]

Right IJ. Yes for pressors.

Why did you extubate the pt if he needed a CVL postoperatively for pressor administration?

 

[Noyac]

I think statistically the IJ is a higher rate of PTX.

I have heard this for years. But I have never seen a PTX from an IJ. But I haven’t seen much from the SC either, except for a handful of surgeons I worked with. For some reason they suck at CVL at my facility.

 

[kmurp]

My one PTX was with an IJ pre ultrasound on a patient crashing in PACU. Weird case. Totally uneventful FESS who arrived in PACU with a BP of 60. No rash or wheezing but she responded to epi so I treated her as anaphylaxis. Until the tryptase came back positive, I thought I had accidentally given her verampamil instead of glyco for reversal as the two vials looked exactly alike. She refused allergy testing so no idea what caused it.