Year : 2019  |  Volume : 22  |  Issue : 1  |  Page : 97--98

Massive subcutaneous emphysema after off-pump coronary bypass surgery


Monish S Raut1, Sumir Dubey2, Ganesh Shivnani2, Arun Maheshwari2, Sibashankar Kar2,  
1 Department of Cardiac Anesthesia, Artemis Hospital, Gurgaon, Haryana, India
2 Department of Cardiac Surgery and Anaesthesiology, Sir Ganga Ram Hospital, New Delhi, India

Correspondence Address:
Monish S Raut
Department of Cardiac Anesthesia, Artemis Hospital, Gurgaon, Haryana
India

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.



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;22:97-98


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 Aug 21 ];22:97-98
Available from: http://www.annals.in/text.asp?2019/22/1/97/250181


Full Text



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}

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

1Aghajanzadeh 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.
2Rojas 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.
3Abu-Omar Y, Catarino PA. Progressive subcutaneous emphysema and respiratory arrest. J R Soc Med 2002;95:90-1.
4Macklin CC. Transport of air along sheaths of pulmonic blood vessels from alveoli to mediastinum. Clinical implications. Arch Intern Med 1939;64:913-26.
5Maunder RJ, Pierson DJ, Hudson LD. Subcutaneous and mediastinal emphysema. Pathophysiology, diagnosis, and management. Arch Intern Med 1984;144:1447-53.
6Beck PL, Heitman SJ, Mody CH. Simple construction of a subcutaneous catheter for treatment of severe subcutaneous emphysema. Chest 2002;121:647-9.