K Sneha
1, MC Rajesh
1,
EK Ramdas
1, Sylesh Aikot
2, George Mathew
Sebastian
2, Shafik Shamsudheen
2
1Department of Anaesthesia, Baby Memorial Hospital,
Kozhikode, Kerala, India
2Department of Surgical Gastroenterology, Baby
Memorial Hospital, Kozhikode, Kerala, India
Address for Correspondence: Dr. Rajesh MC, Department
of Anaesthesia, Pain and Perioperative Medicine, Baby Memorial
Hospital, Kozhikode, Kerala, India. E-mail:
rithraj2@yahoo.co.in
Keywords: leaking chyle, one lung ventilation, prone
ventilation
Introduction
The incidence of lung isolation is on the rise as
thoracoscopic procedures are being performed more frequently.
Moreover, certain procedures require prone or lateral position
also for accessibility. Our main aim during such
surgeries is to prevent hypoxia and to maintain hemodynamic
stability.
Case Report
A middle aged male with rheumatic heart disease, having
moderate to severe aortic regurgitation, moderate mitral
stenosis and mitral regurgitation, underwent uneventful double
valve repair. On post op day 2, chylous leak was noted through
the chest drains, which was not subsiding. So he was referred
to our institution for thoracoscopic ligation of thoracic
duct.
He had no other co morbidities. He was on oral
anticoagulation, which was stopped and Inj Heparin was started
in the preoperative period. Preop investigations showed low
albumin with Albumin/Globulin ratio reversal. All other blood
investigations were within normal limits.
ECG showed a normal sinus rhythm with no signs of ischemia or
chamber enlargement. Echocardiogram showed an ejection
fraction of 59%, with normally functioning valves and no
regurgitation.
Preoperatively, half an hour before the surgery, infective
endocarditis prophylaxis was given with Inj Ampicillin 2gm IV.
Premedication with Inj Midazolam 1mg, Inj Ranitidine
50mg and Inj Glycopyrrolate 0.2mg IV.
The patient was shifted into the operating room. Left radial
artey was cannulated for invasive BP monitoring and ABG
analysis. Right subclavian central line was inserted with 7F
triple lumen catheter. Preinduction monitors were ECG,
pulse oximetry, non invasive blood pressure monitoring. Post
induction monitors were end tidal CO
2,
temperature, neuromuscular monitor and urine output.
He was induced with Inj Fentanyl 100mcg and Inj Etomidate
20mg. Neuromuscular paralysis with Inj Atracurium 50mg. He was
intubated with 41F left double lumen tube and secured after
confirming the position. Ryles tube was also inserted
and position checked.
After induction, patient was put in the prone position, taking
care of all pressure points and making sure ventilation was
adequate. Anaesthesia was maintained with inhalational oxygen,
air, sevoflurane and IV infusion of Fentanyl at fifty
microgram per hour and dexmedetomedine at 0.5 microgram per
hour.
Through the Ryles tube, fat rich mixture (100ml olive
oil and 100ml ice cream powder in water) was given. Before
commencement of thoracoscopy, one lung ventilation was
established.
Intraoperative period was uneventful with, arterial
blood gas analysis after intubation and after surgery showing
PaO
2, PCO
2
and pH within normal range. Ventilatory strategy was pressure
control, volume guarded dual control ventilation. A tidal
volume of 400 to 500ml was attained, with pressure of 27 to 28
mmHg and PEEP of 5cm water. SpO
2 98
to 100% and end tidal CO
2 32 to 34
with respiratory rate 12 to 14 per minute. The thoracic duct
was identified, double clipped and ligated by the surgeon.
After the surgery, the patient was put in supine position.
Thorough Ryles tube suctioning done. Antiemetic measures with
Inj Ondansetron and Inj Metoclopramide. Double lumen
tube was changed to single lumen tube and ventilated.
Gradually neuromuscular reversal was given and extubated when
fully awake. The post op period was uneventful.
Discussion
The major concerns in this case were a patient post double
valve repair, who needed one lung ventilation in prone
position, and was full stomach before extubation.
As he was post double valve repair, infective endocarditis
propylaxis was given as per recommendation, anticoagulants
were continued and valve function was checked. One lung
ventilation was needed for surgical access, and measures to
prevent hpoxia like a Positive End Expiratory pressure of 5 cm
H
2O, maintaining ventilation of both
lungs as far as possible was done [1]. Because we were using
Dexmeditomedine and Fentanyl infusions during surgery, we were
able to ventilate with higher inspired oxygen concentration.
This also helps in our aim to prevent hypoxia during one lung
ventilation. Prone postion was necessary and it actually
helped in improving ventilation when compared to lateral
position with one lung ventilation [2]. As a protocol we use
left sided double lumen tube almost always when lung
separation is required. This is supported by many recent
surveys, wherein anaesthesiologists showed preference to left
sided tubes than right [3]. The margin of safety with left
sided tube is far higher than the right sided once
[4]. All pressure points were padded. The disadvantage was
decreased accessibility to airway in case of desaturation.
Ryles tube feeding with fat rich mixture increased risk of
regurgitation and aspiration at the time of extubation. So
antiemetics were given as a prophylaxis well before planned
extubation. A thorough Ryles tube suctioning was done before
reversal and extubated only when he was fully awake.
References
1. Atul Purohit, Suresh Bhargava, Vandana Mangal, Vinod Kumar
Parashar.Lung isolation,one lung ventilation and hypoxaemia
during lung isolation. Indian Journal Of Anaesthesia 2015;
59:606-17.
2. Yatabe T, Hirohashi M, Fukunaga K, Yamashita K,
Yokoyama M. Comparison of oxygenation during one lung
ventilation in prone position with lateral decubitus position
in esophagectomy. European Journal of Anaesthesia 2010; 27:
99.
3. Alsharani H, Eldawlatly A. Lung isolation algorithm: A
novel template. Saudi J Anaesthesia 2014; 8: 447-8.
4. Robertshaw FL. Low resistance double lumen endotracheal
tubes. Br J Anaethesia 1962;34: 576-9.