ACA App
Annals of Cardiac Anaesthesia Annals of Cardiac Anaesthesia Annals of Cardiac Anaesthesia
Home | About us | Editorial Board | Search | Ahead of print | Current Issue | Archives | Submission | Subscribe | Advertise | Contact | Login 
Users online: 463 Small font size Default font size Increase font size Print this article Email this article Bookmark this page
 


 

 
     
    Advanced search
 

 
 
     
  
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Email Alert *
    Add to My List *
* Registration required (free)  


    Abstract
    References
    Article Figures

 Article Access Statistics
    Viewed383    
    Printed4    
    Emailed0    
    PDF Downloaded31    
    Comments [Add]    

Recommend this journal

 


 
Table of Contents
INTERESTING IMAGES  
Year : 2019  |  Volume : 22  |  Issue : 1  |  Page : 97-98
Massive subcutaneous emphysema after off-pump coronary bypass surgery


1 Department of Cardiac Anesthesia, Artemis Hospital, Gurgaon, Haryana, India
2 Department of Cardiac Surgery and Anaesthesiology, Sir Ganga Ram Hospital, New Delhi, India

Click here for correspondence address and email

Date of Web Publication14-Jan-2019
 

   Abstract 


Subcutaneous emphysema is a condition when air gets accumulated into the tissues under the skin and in the soft tissues of the chest wall or neck but can also spread to other parts of the body. It generally causes minimal symptoms and nonlethal; sometimes, it may be severe and life-threatening if deeper tissues of the thoracic outlet and chest are involved. It is essential to know the mechanisms of subcutaneous emphysema after cardiac surgery.

Keywords: Cardiac surgery, subcutaneous emphysema, pleural space

How to cite this article:
Raut MS, Dubey S, Shivnani G, Maheshwari A, Kar S. Massive subcutaneous emphysema after off-pump coronary bypass surgery. Ann Card Anaesth 2019;22:97-8

How to cite this URL:
Raut MS, Dubey S, Shivnani G, Maheshwari A, Kar S. Massive subcutaneous emphysema after off-pump coronary bypass surgery. Ann Card Anaesth [serial online] 2019 [cited 2019 Sep 15];22:97-8. Available from: http://www.annals.in/text.asp?2019/22/1/97/250181




A 55-year-old female patient presented with chest discomfort for few days. She had no other comorbid conditions. However, the coronary angiographic evaluation revealed a triple vessel coronary artery disease. She underwent off-pump coronary artery bypass grafting surgery (left internal mammary artery to left anterior descending artery, 2 saphenous venous grafts to obtuse marginal and posterior descending artery) uneventfully. Only mediastinal and not pleural drain was inserted while closing the sternum as pleural cavity was not opened. The patient was extubated in a stable condition 8 h after the surgery. Immediate postoperative chest X-ray did not reveal any abnormal finding. On postoperative day 1, patient's face, chest wall and abdomen were swollen with crepitus on palpation. Chest X-ray and computed tomography scan suggested massive subcutaneous emphysema (SE) [Figure 1]. Bilateral pleural drain tubes were inserted, and gradually the SE subsided.
Figure 1: (a) Chest X-ray showing extensive bilateral subcutaneous emphysema in a postoperative patient of coronary artery bypass grafting surgery. (b-d) Computed tomography scan image showing pneumomediastinum and massive bilateral subcutaneous emphysema

Click here to view


SE is a condition when air gets accumulated into the tissues under the skin and in the soft tissues of the chest wall or neck but can also spread to other parts of the body.[1],[2] It can be due to blunt or penetrating trauma, barotrauma, pneumothorax, malignancy, infection, iatrogenic complication, and even spontaneous SE.[2]

In SE after cardiac surgery, air originating from the lung may get into subcutaneous space by two mechanisms.[3] Air in pleural space in case of pneumothorax can pass directly into the chest wall and subcutaneous tissues if the parietal pleura is breached.

Other mechanism can be tracking of alveolar air proximally within the bronchovascular sheath towards the hilum of the lungs and then it may pass superficial to the endothoracic fascia along with the path of least resistance producing SE.[4] Similarly, it may also travel along the mediastinal and then into the cervical visceral space investing the trachea and esophagus.[5] This could have been the possible mechanism in the present case as the patient did not have pneumothorax.

Although SE generally causes minimal symptoms and nonlethal; sometimes, it may be severe and life-threatening if deeper tissues of the thoracic outlet and chest are involved resulting in respiratory impediments and tension phenomena. Various approaches have been elaborated in the management of SE such as the use of subcutaneous incisions, needles, drains, or cervical mediastinotomy.[1],[6]

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Aghajanzadeh M, Dehnadi A, Ebrahimi H, Fallah Karkan M, Khajeh Jahromi S, Amir Maafi A, et al. Classification and management of subcutaneous emphysema: A 10-year experience. Indian J Surg 2015;77:673-7.  Back to cited text no. 1
    
2.
Rojas M, Rojas P, Toro C, Pinto D, Cifuentes C, Henríquez I, et al. Subcutaneous emphysema after ultrasonic treatment: A case report. Int J Odontostomatol 2009;3:67-70.  Back to cited text no. 2
    
3.
Abu-Omar Y, Catarino PA. Progressive subcutaneous emphysema and respiratory arrest. J R Soc Med 2002;95:90-1.  Back to cited text no. 3
    
4.
Macklin CC. Transport of air along sheaths of pulmonic blood vessels from alveoli to mediastinum. Clinical implications. Arch Intern Med 1939;64:913-26.  Back to cited text no. 4
    
5.
Maunder RJ, Pierson DJ, Hudson LD. Subcutaneous and mediastinal emphysema. Pathophysiology, diagnosis, and management. Arch Intern Med 1984;144:1447-53.  Back to cited text no. 5
    
6.
Beck PL, Heitman SJ, Mody CH. Simple construction of a subcutaneous catheter for treatment of severe subcutaneous emphysema. Chest 2002;121:647-9.  Back to cited text no. 6
    

Top
Correspondence Address:
Monish S Raut
Department of Cardiac Anesthesia, Artemis Hospital, Gurgaon, Haryana
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/aca.ACA_135_18

Rights and Permissions


    Figures

  [Figure 1]



 

Top