甲状腺手術後排液ドレーンによる気腫•気胸とその発生機序

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  • Emphysema and pneumothorax caused by the drains following thyroidectomy

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A 76 year old woman underwent a subtotal thyroidectomy without event. A postoperative fiberoptic bronchoscopy induced severe laryngospasm. After a period of labored respiration, subcutaneous emphysema developed around the neck and upper thorax while the chest X-ray film showed a right pneumothorax.<br>An open examination of the surgical wound did not disclose any air leakage from the trachea under the intratracheal positive pressure ventilation.<br>Since there was no reasonable explanation for the emphysema and pneumothorax, a possible mechanism was suspected in which the air was sucked into the tissues through the drains in the wound by a negative pressure created between the muscle layers during the labored respiration.<br>To explore the possibility of this mechanism, animal experiments were performed on five mongrel dogs. The dogs were anesthetized and intratracheally intubated.<br>A transverse incision of about 5cm in length was made in the mid neck area, far from the pleural apex. Several film drains were placed between the muscle layers and around the trachea. After closure of the skin incision, the endotracheal tube was occluded intermittently to prevent instantaneous death. Severe respiratory effort caused an end -inspiratory pressure of about -80mmHg sometime before death.<br>A necropsy of the dogs revealed emphysema in the loose connective tissues between the fascias, the peritracheal region and the upper mediastinum in all dogs and bilateral pneumothorax in one. Serous membrane was taken from the mediastinum and the rupture point of the membrane was found to be between 40 to 80mmHg.<br>We believe that the emphysema and pneumothorax found in this patient might have been caused by a rare mechanism, in which the air was sucked into the subdermal and intrafascial loose connective tissue through the drains by a negative pressure during the labored breathing, and transferred to the mediastinum by a pump action of the muscle layers, finally producing pneumothorax.

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