Intraoperative oxygen embolus and tension pneumocephalus: Is
Published in the Journal of Neuroanaesthesiology and Critical Care, the authors present a case of oxygen embolus and tension pneumocephalus after H2O2 irrigation during craniotomy in supine position.

A 54-year-old male, controlled diabetic, who presented to our hospital with a history of head trauma 2 months ago. He then developed symptoms of intermittent high-grade fever, vomiting, headache on and off. CT scan revealed right subgaleal and subdural empyema secondary to parietal bone osteomyelitis. He was subsequently posted for a craniotomy for drainage of the empyema in the supine position.

In the operation theatre, the patient was sedated with midazolam 2 mg intravenous (IV), fentanyl 150 micrograms IV, subsequently induced with propofol 150 mg IV and vecuronium 6 mg IV. Airway was secured with an 8 mm endotracheal tube. Oxygen, air and desflurane were used for maintenance of anaesthesia.

Craniotomy was performed in supine poistion and wash was given with dilute 3% H2O2. Following this, within 2 min, the end-tidal CO2 dropped from 37 to 19 mmHg and the blood pressure fell from 110/60 to 80/50 mmHg. There was no significant blood loss till that time to attribute to the hypotension. As there was no central line in place, embolism was managed with Durant position, fluids and phenylephrine boluses.

About 100% oxygen was administered; there was no desaturation on the pulse oximeter. Haemodynamic parameters came back to baseline; surgery was continued without any major intraoperative complication. Blood loss was around 100 ml, no blood or blood products were needed. At the end of the procedure, severe hypertension (from 130/84 to 222/120 mmHg) and bradycardia (from 104/min to 60/min) were noted, pupils were sluggish and dilated.

The patient was rushed on a portable ventilator to CT room urgently which showed massive right temporoparietal and occipital pneumocephalus with underlying mass effect and significant midline shift of 7.6 mm and generalised cerebral oedema. The patient was rushed back to the operation theatre. Fentanyl 200 micrograms IV with vecuronium 5 mg IV were given, and emergency burr hole for release of the pneumocephalus was done. The sutures were reopened, Site thoroughly irrigated with normal saline.

The haemodynamic parameters gradually stabilised and remained stable throughout the surgery. At the end of the surgery, pupils were equal and reactive. The patient was shifted to the ICU, sedated with fentanyl infusion and mechanically ventilated. Lack of neurological recovery on the next day prompted a magnetic resonance imaging brain which showed right middle and anterior cerebral artery infarcts and left cerebellar infarcts, with residual right frontotemporoparietal pneumocephalus with an increase in midline shift and mass effect.

There was no neurological recovery 48 h after the second surgery, and he died on the 2nd post-operative day.

Read in detail here: https://pxmd.co/VX0VX
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Dr. B●●●●●●a S●●●●a
Dr. B●●●●●●a S●●●●a Critical Care Medicine
Nice case sharing.
Sep 26, 2018Like1