Iatrogenic tension pneumothorax developed during ventriculo-peritoneal shunt surgery and detected shortly before extubation
© The Author(s) 2018
Received: 5 November 2017
Accepted: 7 May 2018
Published: 12 May 2018
To the editor
Few reports on iatrogenic pneumothorax developed during/after a ventriculo-peritoneal (VP) shunt surgery exist in the literature, but none discusses time of pneumothorax detection. In the presented case, a post-operative review of electronic anesthesia records indicated that diagnosis could have been made earlier and that tension pneumothorax could have been avoided.
A 48-year-old man (158 cm, 65 kg, BMI 26.04) who had undergone clipping after subarachnoid hemorrhage was hospitalized for convulsions at 5 months following initial surgery. VP shunt operation was scheduled. Chest CT showed no pulmonary bullae or blebs before surgery.
Induction of general anesthesia was uneventful. At 140 min, the anesthesiology resident noticed an increase in airway pressure (AP) (to 25 cmH2O) and the attending decided to proceed with anesthesia since no abnormalities on the patient side (change in pulse oximetry readings or abnormal sounds on auscultation) or on the circuit side (endotracheal tube occlusion, kinking, anesthetic machine malfunction) were found. Arterial blood gas analysis showed pH 7.444, PaCO2 35.2 mmHg, PaO2 147 mmHg, and SaO2 98.4%. Peak pressure stayed at 25–29 cmH2O. The attending concluded that increased AP was caused by patient’s position and/or patient’s body weight.
Following decompression, oxygen saturation returned to 100%. A chest X-ray taken a few minutes later revealed massive subcutaneous emphysema, right pneumothorax, and mediastinal shift to the left (Fig. 1b, c). After insertion of a chest drainage tube, the patient was extubated and transferred to the intensive care unit. Continuous air leakage was observed for few days postoperatively indicating intra-operative iatrogenic pleural and lung injury. The chest tube was removed on POD7. The patient was discharged and transferred to a rehabilitation hospital for further treatment on POD15.
In the literature, in most reported cases, pneumothorax occurred after ventriculo- or subduro-peritoneal shunt surgery [1–5], but in our case, tension pneumothorax occurred shortly before extubation. Time of pneumothorax detection is crucial for early diagnosis and treatment, and early detection could be facilitated by careful examination of electronic anesthesia records. In our case, the assessment indicated that the diagnosis could have been made earlier and tension pneumothorax progression could have been avoided—the resident reported AP changes 30 min after AP had actually begun to increase (Additional file 1), and timing of AP increase coexisted with surgical maneuvers in the neck region. The pleural tear caused by the passer might have acted as a check valve before returning the patient’s head position. Ultrasonography was useful to confirm the diagnosis and guide thoracentesis .
Availability of data and materials
All data generated or analyzed during this study are included in this published article and its supplementary information files.
YH conducted anesthetic management to the patient and drafted manuscripts. TH helped revise the manuscript. IU collected anesthetic data. YM collected anesthetic data and made the graph. SO supervised the writing of the manuscript. All authors read and approved the final manuscript.
Consent for publication
Written consent has been obtained from the patient’s relatives (mother).
The authors declare that they have no competing interests.
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- Portnoy HD, Croissant PD. Two unusual complications of a ventriculoperitoneal shunt. Case report. J Neurosurg. 1973;39:775–6.View ArticlePubMedGoogle Scholar
- Menguy E, Mangez JF, Roux P, Alibert F, Winckler C. Pneumothorax apres mise en place d ’ une derivation Pneumothorax following ventriculo-peritoneal shunt procedure; 1986. p. 615–6.Google Scholar
- Schul DB, Wolf S, Lumenta CB. Iatrogenic tension pneumothorax resulting in pneumocephalus after insertion of a ventriculoperitoneal shunt: an unusual complication. Acta Neurochir. 2010;152:143–4.View ArticlePubMedGoogle Scholar
- Solmaz I, Tehli O, Kaya S, Erdogan E, Izci Y. Bilateral pneumothorax during subdural-peritoneal shunting. Turk Neurosurg. 2011;21:421–2.PubMedGoogle Scholar
- Kono K, Tomura N, Okada H, Terada T. Iatrogenic pneumothorax after ventriculoperitoneal shunt: an unusual complication and a review of the literature. Turk. Neurosurg. 2014;24:123–6.PubMedGoogle Scholar
- Volpicelli G. Sonographic diagnosis of pneumothorax. Intensive Care Med. 2011;37:224–32.Google Scholar