Massive airway bleed in prone position-An unforeseen complication in scoliosis surgery

Dear Editor,

Massive airway bleed in prone position represents an anesthetic emergency.

A 14-year-old girl with adolescent idiopathic thoracolumbar scoliosis extending from D₁ to L₁ vertebra with cobb’s angle of 48.5° with moderate restriction of pulmonary function tests was posted for posterior spinal correction, instrumentation and fusion [Figure 1]. After intravenous induction and smooth first attempt intubation, right internal jugular vein and radial artery were cannulated.

Figure 1.

MRI showing thoracolumbar scoliosis

The patient was made prone, prepared and draped. About 40 ml of 2µg/ml adrenaline saline was administered by the surgeon via paraspinal route. Towards end of infiltrations, Heart rate and blood pressure raised to more than 150/minute and 154/100 mmHg respectively. The surgeon stopped infiltrating further, propofol bolus was administered and vitals returned to normal. Bouts of 100–150 ml fresh blood gushed into breathing circuit in next five minutes’ time [Figure 2].

Figure 2.

Bloody circuit and endotracheal tube

Immediately patient was made supine. Vitals were stable. and SpO₂ was 100%. Air entry was equal with bilateral crepitations. On endotracheal tube (ETT) suction, blood clots were obtained and therefore reintubated with same sized tube fearing tube block. Fiberoptic bronchoscope was not available. Rigid bronchoscopy done by thoracic surgeon revealed normal trachea with clots in both bronchi and there was no active bleeding. Case deferred and patient was extubated. Post-operative period was uneventful except for occasional dry cough.

The concerns were possible obstruction of endotracheal tube by clots along with hemodynamic compromise in the prone position. Four probable causes for the bleed were considered.

1. Airway bleed following central venous cannulation:[1,2] Unlikely in this case, because bleeding was 20 minutes after cannulation, single episode with no hemodynamic compromise. Chest X-ray showed aberrant course of central venous catheter [Figure 3] which turned out to be left sided superior vena cava in Computed Tomography (CT). There was no blood collection in atrioventricular groove or pericardium in CT.

2. Pulmonary/Bronchial arteriovenous malformation was ruled out later by CT angiogram thorax.

3. Trauma to the tracheobronchial tree was ruled out by rigid bronchoscopy, chest X-ray and CT thorax. There was no air leak and subcutaneous emphysema.

4. Lung injury by paraspinal infiltration: CT showed narrow posterior skin to lung distance of 2.5–2.8 cm, at D_6-7 level along with hemorrhagic consolidation of left lower lobe corresponding to the same vertebral level [Figure 4].

Figure 3.

Chest X-ray showing aberrant course of CVC

Figure 4.

CT showing narrow posterior skin to lung distance

Inadvertent vascular puncture (6.8%), pleural puncture (0.8%) and pneumothorax (0.5%) are reported complications of paravertebral injections.[3] A similar case of pulmonary hemorrhage has been reported after paravertebral block in a patient with previous thoracic surgery.[4]

The purpose of reporting this case is to make readers aware of three important facts.

1. Caution should be exercised with infiltrations in terms of dose of adrenaline, depth of infiltrations and pre-injection aspiration. Ultrasound guidance must be used for paraspinal infiltrations especially in patients with abnormal anatomy and previous thoracic surgeries.

2. Good team work is required when such a catastrophe occurs in prone position.

3. This incident reveals the importance of radiological confirmation of course of central venous catheter, lack of which created a diagnostic dilemma in this case.

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