64-year-old female with a history of depression on escitalopram and quetiapine initially presented from outside provider with right-sided abdominal and flank pain who was later diagnosed with hydronephrosis with ureteral dilation secondary to high grade mid-ureteral transitional cell carcinoma. The patient was scheduled for right sided robotic nephroureterectomy.
The preoperative evaluation was unremarkable. The patient was induced with 50mcg fentanyl, 30mg lidocaine, 130mg propofol, and 100mg succinylcholine. Grade one view was seen on intubation and endotracheal tube was placed without complications. The patient was initially maintained on sevoflurane which was later changed to desflurane. Other maintenance medications included additional doses of fentanyl and hydromorphone. The patient was paralyzed throughout the case using vecuronium. The case proceeded uneventfully.
Postoperatively the patient was noted to be restless and disoriented. In the post anesthesia care unit, the patient was maintained on 10L O2 by simple face mask. On physical exam, the patient was noted to have bilateral chest and neck crepitus. A chest x-ray was ordered and were reviewed briefly at bedside. The patient continued to complain of pain though remained disoriented, drowsy, and unable to effectively communicate. The patient was weaned to 6L O2 by simple face mask and transferred to the floor.
The patient was weaned to 2-3L O2 by nasal cannula on the floor. The anesthesia team was called to beside to evaluate for confusion. It was determined that her presentation was consistent with postoperative hypoactive delirium given stable vital signs, no hypoxia on 2-3L O2 by nasal cannula, and normal laboratory values. Again bilateral chest and neck crepitus was noted and thought to be secondary to the laparoscopic procedure.
On POD#1, final radiologist interpretation of the chest x-ray taken in PACU revealed large right-sided pneumothorax, extensive chest wall and lower neck soft tissue emphysema, pneumomediastinum, and mild pneumoperitoneum. Based on radiographic findings a chest tube was placed with re-expansion of the right lung. An attempt to transition the chest tube to water seal on POD#2 failed due to re-accumulation of the pneumothorax. Subsequent attempt to transition the chest tube to water seal on POD#4 was successful. The chest tube was eventually removed on POD#5. There was no re-accumulation of the pneumothorax 4 hours following chest tube removal on chest x-ray. The patient was discharged without further complications.
