Anaesthetic considerations in primary repair of tracheobronchial injury following blunt chest trauma in paediatric age group: Experience of two cases
A 14-year-old boy presented in the emergency department with a history of blunt injury to chest (run over by bullock cart) with respiratory insufficiency and episodes of vomiting with frank blood. On examination, child was irritable, tachypneic, with feeble peripheral pulses with features suggestive of left sided pneumothorax. An urgent bed side chest X-ray showed left pneumothorax []. After intercostal drain (ICD) insertion at 5th intercostal space his saturation improved to 95%. Continuous air leak was noticed through ICD tube and computerised tomography (CT) thorax revealed left main bronchus distal portion tear with severe collapse of the left lung (‘fallen lung sign’), left subclavian artery complete thrombosis with suspicious injury to left inferior pulmonary vein. Laboratory investigations revealed Bombay O blood group, haemoglobin = 9.3 g/dl, haematocrit = 25.6, other blood and urine investigations were normal. Though CT scan showed subclavian artery thrombosis, clinically there were no signs of ischaemia of limb and also radial and ulnar artery pulsations were felt moderately. Thus, patient was started on heparin 2500 IU empirically.\nAn immediate diagnostic bronchoscopy and posterolateral thoracotomy was planned. Written informed high-risk consent was taken. In the operating room, pre-operative vitals were heart rate = 112/min, blood pressure = 96/60 mmHg, SpO2= 95% with O2 support. After pre-oxygenation, patient was pre-medicated with intravenous glycopyrrolate 0.2 mg and fentanyl 40 μg. The patient's trachea was intubated with a 6-mm cuffed single lumen endotracheal tube (ETT) after induction with thiopental sodium and succinylcholine. Complete transection of the left main bronchus was confirmed with fibre optic bronchoscopy (FOB) and right endobronchial intubation and one lung ventilation (OLV) was achieved. Anaesthesia was maintained with isoflurane in 100% O2 and atracurium. Once bronchial transection repaired, ETT was pulled out of right bronchus and placed above the carina, both lungs ventilated saturation of 98-99% ensured. Post-repair, no air leak noticed with positive pressure ventilation and patient was extubated after confirming adequate respiratory efforts. Follow-up chest X-ray showed incomplete expansion of the left lung due to underlying contusion. ICD removed on 11th post-operative day. Child was discharged after 12 days.