Article Type: Case Report
Received date : 27/05/2018
Accepted date : 20/07/2018
Published date: 27/07/2018
Corresponding author: Gahlot D*, Saxena K N, Taneja B, Mishra D
Department of Anesthesiology, Maulana Azad medical college and associated hospitals, New Delhi , India.
Article Type: Case Report
Received date : 27/05/2018
Accepted date : 20/07/2018
Published date: 27/07/2018
Diaphragmatic hernia is congenital or acquired defect in diaphragm resulting in herniation of abdominal viscera into thoracic cavity. Acquired diaphragmatic hernia are rare and seen mostly in patients with blunt or penetrating abdominal injuries. Non traumatic acquired diaphragmatic hernias have been reported in literature but are extremely rare. Anesthetic management of patients with diaphragmatic hernia as a coexisting disease in adults is not adequately described in literature owing to its rarity. We report successful anesthetic management of an adult male who had osteoarthritis of left knee with long standing asymptomatic right diaphragmatic hernia as a coexisting disease scheduled for left total knee replacement.
Keywords: Diaphragmatic hernia; Anesthetic management
Diaphragmatic hernia is congenital or acquired defect in diaphragm resulting in herniation of abdominal viscera into thoracic cavity. Congenital diaphragmatic hernia occurs because of embryological defect in the diaphragm and usually presents immediate after birth . Acquired diaphragmatic hernias are rare and seen mostly in patients with blunt or penetrating abdominal injuries. Non traumatic acquired diaphragmatic hernias have been reported in literature but are extremely rare .Putative causes for non-traumatic diaphragmatic hernias include physical exertion, pregnancy, labor and delivery, sneezing or coughing, and even ingestion of a large meal .
We report successful anesthetic management of an adult male who had osteoarthritis of left knee with long standing asymptomatic right diaphragmatic hernia as a coexistingdisease scheduled for left total knee replacement. No case of long standing asymptomatic diaphragmatic hernia as a coexisting disease has been reported in the literature so far.
A 66 year old male scheduled for left total knee replacement in view of osteoarthritis of knee presented to preanesthetic clinic. Patient was a known case of hypertension for the past 10 years controlled on oral ramipril 2.5 mg and hydrochlorthiazide 12.5mg once daily. There was no history of dyspnea, orthopnea, chest pain, paroxysmal nocturnal dyspnea. The functional capacity of the patient was difficult to assess as the patient had difficulty in walking because of osteoarthritis. Breath holding time was found to be 18 seconds. On auscultation breath sounds were found to be reduced on right side. Heart sounds were normal. X- Ray chest showed homogenous radio opacity obscuring right mid and lower zone likely to be either consolidation or collapse or effusion(fig. 1). Ultrasound chest reported non tapable pleural effusion.
Figure 1: Chest X-Ray showing homogenous opacity right mid zone and lower zone.
Radiologist advised a CECT abdomen in view of chest x ray changes which reported right diaphragmatic hernia with herniation of liver, omental fat and hepatic flexure into right thoracic cavity(fig.2).
Figure 2: CECT abdomen showing right diaphragmatic hernia with herniation of liver,omental fat, and hepatic flexure.
Herniated abdominal viscera was causing compression and displacement of heart and mediastinum towards left side with compression of right and left atria and splaying of right pulmonary vessels. Basal atelectasis of the right lung was also reported. Pulmonary function tests showed mild restrictive pattern with FVC 77%, FEV1 86%, FEV1/FVC of 105%.
Rest of the medical and surgical history was not significant and no abnormality was detected in airway and spine examination. On further cross examination, patient gave history of right diaphragmatic hernia for past 10 years without any symptoms of dyspepsia, dyspnea, orthopnea or syncope. All the preoperative biochemical investigations were normal. A surgical opinion was sought in the preoperative period for diaphragmatic hernia. As the patient was asymptomatic and pulmonary function tests showed mild restrictive pattern no surgical intervention was advised. Patient was planned for left Total knee replacement under combined spinal epidural anesthesia.
In the operating room, routine monitoring was done including electrocardiography, non-invasive blood pressure, pulse oximetry and I.V cannulation was secured. His baseline BP was 140/90 mm hg, HR was 82/min, O2 saturation of 97% on room air. Epidural catheter was inserted at L3-L4 intervertebral space catheter was fixed at 10 cm. Subarachnoid block was given at L4-L5 intervertebral space 2.5 ml of 0.5% bupivacaine heavy was given. Level of block achieved was T10- T12.Patient’s vitals remained stable during the surgery. Epidural catheter dosing was not required intraoperatively as the duration of surgery was not prolonged. The catheter was placed to supplement the level of block in case the duration gets prolonged. The surgical procedure lasted for 2hrs. Postoperative stay of the patient was uneventful patient was discharged on 2nd postoperative day.
Diaphragm is the largest respiratory muscle separating thorax from the abdominal cavity .Diaphragmatic hernia is defect in the diaphragm which may be congenital or acquired causing abdominal organs to herniate into the thoracic cavity. While congenital diaphragmatic hernias are due to defect that progresses at the embryologic period, acquired defects which are rare occur because of trauma in 75% of cases. Only few reported cases have not involved some type of obvious damage or injury [4, 5].Traumatic diaphragmatic hernia presents as an acute condition in patients with history of trauma with cardiorespiratory function compromise and requires immediate corrective surgery. Severity of coexisting injuries is the major determinant of higher mortality in these patients. General anesthesia with rapid sequence induction remains the standard technique in these patients .The patient we report here had no history of trauma and had no specific symptoms such as dyspnea, tachypnea, cough, chest or abdominal pain. Diaphragmatic hernia was an incidental finding preoperatively in the present case, which on further questioning was told by the patient to be present for past 10 years.
Anesthetic management of patients with diaphragmatic hernia as a coexisting disease in adults is not adequately described in literature owing to its rarity. We had the opportunity to prepare ourselves for possible difficulties and complications that were expected in this condition. Since the surgery could be done under central neuraxial block, combined spinal epidural was anesthesia of choice in the present case. In patients of diaphragmatic hernia, respiratory compromise can occur with high level of block in regional anesthesia because of blockade of the muscles of respiration and reduction in inspiratory capacity and expiratory reserve volume .Therefore, careful titration of local anesthetics should be done in these patients to prevent high level of block.We gave spinal anesthesia with low volume of drug so that high level was not achieved and the epidural catheter provided backup in case of very low spinal levels and for maintaining the level of blockade when there was recession of the level of blockade. It permitted the advantage of an early onset of effect as well as the flexibility of graduated doses of local anaesthetics through epidural catheter. This not only helped to titrate the level of block but also was advantageousin maintenance of hemodynamic stability. Fayeem and Fayad reported spontaneous diaphragmatic rupture in a patient with diaphragmatic eventration after lower limb surgery under epidural anesthesia, the probable mechanism of which was explained to be an increase workload of the diaphragm due to high regional block .
Another concern is the positioning in these patients. Supine positioning during the procedure causes reduction in functional residual capacity and may increase the herniation of abdominal viscera into thoracic cavity increasing the respiratory compromise in these patients .Specific positions which causes further reduction in functional residual capacity such as trendelenburg and lithotomy positions should be used with cautiously in these patients.
Although, general anesthesia is not the anesthesia of choice in the present case but it is important to understand the difficulties in its administration. Administration of general anesthesia needs higher vigilance and offers greater difficulties in these patients as compared to regional technique. In patients with abdominal viscera occupying a large portion of the thoracic cavity, a higher risk of regurgitation, aspiration, hypoxemia, and hemodynamic compromise should be considered . Tracheal intubation difﬁculties may also be encountered because of mediastinal shift and deviation of the trachea in these patients. Direct compression of mediastinum, inferior vena cava and pulmonary veins caused by mass effect impairs venous return to the heart and decreases cardiac output. Administration of positive pressure ventilation further compromises the venous return and poses a higher risk of intraoperative hemodynamic instability in these patients . Nitrous oxide use causes expansion of intra-abdominal viscera and increases the herniation and mediastinal shifting causing further respiratory and circulatory impairment .Thus, use of nitrous oxide should be avoided in these patients. All the measures should be taken to prevent increase in intra abdominal pressure such as coughing, bucking, and lighter planes of anesthesia. Increase in intra abdominal pressure increases the herniation of contents into thorax causing increase in respiratory and circulatory compromise [8,10].
Peripheral nerve block - femoral sciatic nerve block is a known approach for total knee replacement surgeries. Compared with neuraxial anesthesia it minimizes hypotension, ensures better hemodynamic stability and less respiratory compromise. Thus, femoral sciatic nerve block is a good alternative anesthetic approach in the present case scenario. However, increased induction time and requirement of expertise may be the limiting factor of using this approach .
We conclude that non traumatic diaphragmatic hernias are a rare entity in adult patients which require meticulous and appropriate anesthetic management. A thorough evaluation of patient in the preoperative period can help identify these rare disorders and thus give us the opportunity to prepare ourselves for the possible difficulties and complications during the surgery. Central neuraxial block is advantageous as compared to general anesthesia in these patients owing to its greater hemodynamic stability and lesser respiratory compromise. However, caution should be excercised to prevent higher level of block in these patients.
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