Tension pneumothorax after ultrasound guided internal jugular venous catheterization in an inadvertently endobronchially intubated patient with kyphosis

Corresponding author: IL-Ok Lee, M.D., Ph.D., Department of Anesthesiology and Pain Medicine, Guro Hospital, Korea University College of Medicine, 97, Gurodong-gil, Guro-gu, Seoul 152-703, Korea. Tel: 82-2-2626-3234, Fax: 82-2-851-9897, E-mail: [email protected] This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http:// creativecommons.org/licenses/by-nc/3.0/), which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. CC Ultrasound guidance has been promoted as a means of reducing the risk of complications during central venous catheterization (CVC), and during internal jugular venous catheterization (IJV), and ultrasound guidance has been reported to reduce the risk of mechanical complications and catheterplacement failures and the time required for insertion [1]. Mild kyphosis or scoliosis does not change cardiopulmonary function, but more aggravated deformities of spine have detrimental effects [2]. Complex interactions during head and neck movement and the fixed insertion depths of preformed endotracheal tubes often cause inadvertent malposition and may result in accidental extubation or inadvertent endobronchial intubation [3]. We report the case of a 53-year-old female patient with kyphosis who was inadvertently endobronchially intubated and rapidly developed tension pneumothorax after ultrasound guided IJV cannulation. A 53-year-old female patient (133 cm tall and 51.5 kg) with a diagnosis of kyphoscoliosis was admitted for posterior correction and fusion. At age 20, she contracted tuberculosis of spine and the kyphoscoliosis subsequently progressed to a kyphosis angle of 90 degrees one year prior to admission. No abnormal chest X-ray, pulmonary function test, laboratory result, or electrocardiogram findings were evident. Lidocaine (40 mg) with 1% propofol (Aquafol, Daewonpharm, Seoul, Korea) and remifentanil (Ultiva, GlaxoSmithKline, UK) (Pion TCI, Bionet, Seoul, Korea) were administered at target concentrations of 4 μg/ml and 3 ng/ml, respectively for induction. After administering 45 mg of rocuronium, the trachea was intubated with a 7.0 mm armored endotracheal tube, and before fixing the tube 20 cm to incisors, lung sounds, chest wall movement in both lung fields, and endotracheal tube depth were confirmed; initial peak inspiratory pressure (PIP) was 15 ± 1 cmH2O. The neck area was prepared and a 7.5-MHz linear-array ultrasound probe, which was connected to a realtime ultrasound unit (SonoSite, Bothell, USA). The probe was covered with ultrasonic gel, wrapped in a sterile plastic sheath and focused at a depth of 4.5 cm. Standard ultrasound two-dimensional (2D) imaging was used to measure the depth and caliber of the IJV, which was found to be patent, compressible, and without thrombi. Catheteri zation was performed with a 19-gauge, 10-cm needle under continuous dynamic observation and real-time 2D images were obtained by placing the transducer parallel and superior to the clavicle, and over the groove between the sternal and clavicular heads of the sternocleidomastoid muscle. For left side CVC, the patient’s head was rotated to the right, but several attempts at left IJV cannulation failed. During an attempt to catheterize the left subclavian vein, vital signs changed to blood pressure 65/47 mmHg, heart rate 70 beats/min, and oxygen saturation 84%. We immediately converted to manual ventilation with 100% O2, but severe resistance was experienced with a PIP 35 ± 4 cmH2O. A chest radiograph revealed unilateral tension pneumothorax in right lung and right endobronchial intubation (Fig. 1). The patient’s head was then rotated to the neutral position and the intubation tube was withdrawn to 17 cm from the incisors. Needle aspiration was immediately performed and a chest tube