Are electrocardiogram changes the first sign of impending peri‐operative pneumothorax?

Abstract

SummaryA patient in the right lateral position underwent left nephrectomy, after which he was placed supine for insertion of The diagnosis of intra-operative pneumothorax canThe peak inspiratory pressure was increased slightly from occasionally be difficult. We report a case where a decrease 14-16 cmH,O in the supine position to 20-22 cmH,O in electrocardiogram (ECG) amplitude was the first sign of when he was in the lateral position. The ECG demonthe event. This change occurred 25 min before a rapid strated sinus rhythm and was similar to the pre-induction deterioration in the patient's clinical condition necessitated ECG (Fig. I). Following nephrectomy he was moved to the urgent treatment.supine position in preparation for the A-V shunt placement. Re-assessment of airway and monitors showed no changes. Ten minutes later, during the preparation of the left upper arm, the lead I1 ECG tracing was noted to be dramatically reduced in amplitude (Fig. 2) when compared to the pre-induction tracing (Fig. I). Re-examination of the Case historyA 55-year-old male patient with progressive renal insufficiency and a left renal mass presented for left nephrectomy and arteriovenous (A-V) shunt placement. His past medical history included well-controlled hypertension, Crohn's disease, progressive renal insufficiency, and a history of cigarette smoking. Medications included atenolol and sulfasalazine. He underwent a n uncomplicated induction of anaesthesia and tracheal intubation. A radial arterial line was placed after induction of anaesthesia and he was positioned in the right lateral decubitus position for surgery. He remained haemodynamically stable during the nephrectomy with a mean arterial pressure (MAP) of 75-85mmHg, and an oxygen saturation (Spo,) of 98%.

Pneumothorax during laparoscopy

“…It complements the clinical experience of Botz and Brock-Utne [1], who reported decreased amplitude of the QRS complex during an open left nephrectomy complicated by pneumothorax. They indicated that these ECG changes may be the first sign of impending pneumothorax [6].…”

“…Our experimental evidence shows that reliable detection of pneumothorax size <100 ml was repeatedly demonstrated in the animal model. Although other reports have described other pathophysiologic changes as early indicators of pneumothorax, this study is the first to quantify the sensitivity of any one modality [1,4,8]. However, other reports have been based on clinical experience, whereas we cannot be certain that our findings will translate exactly to humans.…”

“…Additionally, ECG changes have been reported in patients who present with spontaneous pneumothorax and those who have experienced an intraoperative pneumothorax [1,5]. To objectively evaluate changes in ECG patterns induced by a pneumothorax, we used an animal model.…”

Trends in electrocardiographic R-wave amplitude during intraoperative pneumothorax

“…Diagnosis of intra-operative pneumothorax is important (4,5). The diagnosis is one of exclusion, as initial changes in vital signs such as cardiorespiratory decompensation and difficulty with ventilation are non-specific, and other causes of such changes are more common (5).…”

Unusual complications of laparoscopic totally extraperitoneal inguinal hernia repair

“…Difficulty obtaining proper ventilation and peak inspiratory pressures shown by airway manometry are suggestive of a pneumothorax 10 . There were case reports suggesting that a pneumothorax, particularly on the left side, may be heralded by a decrease in the amplitude of the ECG or other non‐specific ECG changes 12 . A prompt patient examination is necessary to detect asymmetrical chest movement and decreased air entry consistent with a pneumothorax.…”