Does bilateral thoracic sympathectomy predispose to reflex bronchospasm following tracheal intubation?

A 31 year old old non-smoking woman, 60 kg, withouth a history of allergy or asthma was scheduled for left knee arthroscopy. Two months previously she had an uneventful general anesthetic for bilateral thorascopic sympathectomy to treat essential hyperhidrosis.

Immediately following intubation, ventilation became difficult. Chest auscultation revealed bilateral expiratory wheezing associated with decreased air entry and increased airway pressure up to 60 cm H2O. Oxygen saturation, as monitored by pulse oximetry, decreased from 100% to 80%.

The severe bronchospams occured immediately following tracheal intubation, suggesting that it may have been a reflex response which was triggered by instrumentation of the airway under light level of anesthesia.

Sympathectomy results in a decrease of plasma norepinephrine, and parasympathetic predominance which may increase airway resistance.

Thus, patients with essential hyperhidrosis who have undergone bilateral thoracic sympathectomy, may be more liable to develop reflex bronchospams under light levels of anesthesia.

Ahed Zeidan MD
Nazih Nahle MD
Anis Baraka MD FRCA
Sahel General Hospital, American Universisty of Beirut Medical Center

Hypoxaemia is of a major concern during thorascopic sympathectomy

Hypoxaemia is of a major concern during thorascopic sympathectomy. However, the pathophysiology of hypoxaemia and consequent decrease in SpO2 differs between the two anaesthetic techniques.

The normal physiological response to massive atelectasis is an increase in pulmonary vascular resistance (hypoxic pulmonary vasoconstriction) with re-routing of blood to well ventilated lung zones and consequent improvement in PaO2. HOWEVER, DURING ENDOBRONCHIAL ANAESTHESIA FOR THORACIC SYMPATHECTOMY THERE IS AN APPARENT FAILURE OF THIS COMPENSATORY MECHANISM. When more then 70% of the lung is atelectatic, compensation by hypoxic pulmonary vasoconstriction appears ineffective.

During carbon dioxide insufflation using endobronchial intubation, Hartrey and colleagues reported a decrease in systolic arterial pressure of >20mm Hg in 21% of patients. Similarly we have reported sudden hypotension and bradycardia after injudicious carbon dioxide insufflation.

Although extremely rare, sudden cardiac arrest has been reported after left T2-3 sympathetic nerve transection. While the exact pathophysiology of this occurence is unclear, it is postulated that before complete transection of the sympathetic trunk, continuous sympathetic stimulation to the stellate ganglions results in a reduction in the ventricular finrillation threshold, arrhythmia and cosequent cardiac arrest.
In an iteresting study of the delayed cardiac effects of T2-$ symtpathectomy, Drott and colleagues demonstrated significantly reduced heart rate at rest, and during both exercise and the recovery phase of exercise. Changes is the electrical axis and shortening of the QT interval have also been reported.

Irrespective of the technique used the reported incidence of postoperative pneumpthorax is variable, occuring in 2-15% of cases.
In a study by Gothberg, Drott and Claes, postoperative chest x-ray after 1274 procedures, in 602 patients demonstrated that a small apical pneumothroax was a usual occurence.

Conclusion: Because of the anaesthetic implications and possible surgical complications, many surgeons are reluctant to perform transthoracic sympathectomy.

British Journal of Anaesthesia 1997; 79: 113-119
B. Fredman, D. Olsfanger and R. Jedeikin

Left, but not right, one-lung ventilation causes hypoxemia during endoscopic transthoracic sympathectomy

Anesth Analg 2000;90:28
© 2000 International Anesthesia Research Society

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CARDIOVASCULAR ANESTHESIA

Sequential Changes of Arterial Oxygen Tension in the Supine Position During One-Lung Ventilation

Seiji Watanabe, MD, Eiko Noguchi, MD, Shinichi Yamada, MD, Nobuya Hamada, MD, and Tatsuhiko Kano, MD

Department of Anesthesiology, Kurume University School of Medicine, Fukuoka, Japan

Implications: Close observation and prompt counteractions including termination of one-lung ventilation (OLV) are crucial for patients under OLV in the supine position, because life-threatening hypoxemia frequently occurs approximately 10 min after starting OLV, even under 100% oxygen inhalation. The left semilateral decubitus position was as effective as the left lateral decubitus position in avoiding life-threatening hypoxemia during OLV.

Incidence of chest wall paresthesia after needlescopic video-assisted thoracic surgery for palmar hyperhidrosis

Alan D.L. Sihoe, Clement S.K. Cheung, Ho-Kei Lai, Tak-Wai Lee, Kin-Hoi Thung, Anthony P.C. Yim^*

Department of Surgery, Division of Cardiothoracic Surgery, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong SAR, China

Received 5 September 2004; received in revised form 28 September 2004; accepted 22 October 2004.

^* Corresponding author. Tel.: +86 852 2632 2629; fax: +86 852 2647 8273. (E-mail: yimap@cuhk.edu.hk).

Objective: Chest wall paresthesia is a reported sequela of thoracotomy and Video-Assisted Thoracic Surgery (VATS) which is distinct from wound pain. Although needlescopic VATS confers less post-operative pain and better cosmesis, the incidence of paresthesia after needlescopic VATS has not been quantified. Methods: For homogeneity of the patient cohort, we studied 50 patients who received bilateral needlescopic VATS sympathectomy (T2-T4 excision) for palmar hyperhidrosis using 2 or 3mm instruments during a 36-month period at a single institute. A standard questionnaire was administered by telephone interview, with 34 patents responding (68.0%). The median post-operative observation time was 16.5 months (range: 10–40 months). Collected data were compared with a historical group who received conventional VATS using 10mm ports. Results: Paresthetic discomfort distinguishable from wound pain was described by 17 patients (50.0%). The most common descriptions were of ‘bloating’ (41.2%), ‘pins and needles’ (35.3%), or ‘numbness’ (23.5%) in the chest wall. The paresthesia resolved in less than two months in 12 patients (70.6%), but was still felt for over 12 months in three patients (17.6%). Post-operative paresthesia and pain did not impact on patient satisfaction with the surgery, whereas compensatory hyperhidrosis in 24 patients (70.6%) did (P=0.001). The rates and characteristics of the paresthesia following needlescopic VATS are similar to those observed after conventional VATS. Conclusions: Chest wall paresthesia affects a significant but previously overlooked proportion of patients following needlescopic VATS

The effects of hypoxemia, G-6-PD deficiency and sympathectomy might all add to the development of acute pulmonary edema

Transaxillary endoscopic sympathectomy of thoracic ganglia (T₂-T₃) has recently gained wider acceptance as the treatment of choice for palmar hyperhidrosis. It requires one-lung ventilation to facilitate the surgery. One-lung ventilation, however, is not without complications, among which acute pulmonary edema has been reported. In this case report, we present a patient with palmar hyperhidrosis complicated by glucose-6-phosphate dehydrogenase (G-6-PD) deficiency, who received bilateral endoscopic sympathectomy under alternate one-lung anesthesia, and developed acute pulmonary edema immediately after recruitment of the successive collapsed lung. The effects of hypoxemia, G-6-PD deficiency and sympathectomy might all add to the development of acute pulmonary edema secondary to reexpansion of each individual lung after alternate one-lung ventilation. The possibilities of the inferred causes are herein discussed.

Source: Acta Anaesthesiologica Scandinavica, Volume 45, Number 1, January 2001

Haemodynamic changes during thoracoscopic surgery

Haemodynamic changes during thoracoscopic surgery: The effects of one-lung ventilation compared with carbon dioxide insufflation.

Main Articles

Anaesthesia. 55(1):10-16, January 2000.
Brock, H. 1; Rieger, R. 2; Gabriel, C. 3; Polz, W. 4; Moosbauer, W. 1; Necek, S. 5

Abstract:
Summary: We investigated the haemodynamic and respiratory effects of one-lung ventilation and carbon dioxide insufflation in 13 adult patients undergoing video-assisted thoracoscopy. Cardiorespiratory variables were determined during carbon dioxide insufflation at intrahemithoracic pressures of 5, 10 and 15 mmHg, and after 5 and 15 min of one-lung ventilation. Carbon dioxide insufflation was associated with a clear deterioration in circulatory function. The cardiac index decreased subsequent to increasing intrathoracic pressures. The mean cardiac index (SD) at pressures of 10 and 15 mmHg was 1.86 (0.39) and 1.52 (0.46), respectively, and may be compared with the reduced venous return consistent with tension pneumothorax. One-lung ventilation did not affect haemodynamic variables but reduced arterial oxygenation indices (PaO2/FIO2) from 424.29 (160.79) after induction of anaesthesia, to 207.72 (125.50) after 5 min and 172.04 (72.03) after 15 min of one-lung ventilation, respectively. The oxygenation index was not influenced by intrahemithoracic carbon dioxide insufflation. One-lung ventilation via a double-lumen endobronchial tube is safe and convenient for video-assisted thoracoscopic surgery. It has no further consequences on haemodynamic variables, whereas the compression of the lung by carbon dioxide insufflation may cause circulatory dysfunction.

one-lung ventilation causes hypoxemia during endoscopic transthoracic sympathectomy

Hypoxemia is an abnormal deficiency in the concentration of oxygen in arterial blood (Mosby's Medical Dictionary). A frequent error is made when the term is used to describe poor tissue diffusion as in hypoxia. It is possible to have a low oxygen content (e.g., due to anaemia) but a high PO₂ in arterial blood so incorrect use can lead to confusion.

Journal of Vascular Surgery : Reply - Published by Elsevier

2 Y Katz, E Zisman, S Isserles and B Rosenberg,
Left, but not right, one-lung ventilation causes hypoxemia during endoscopic transthoracic sympathectomy.

ETS sympathetically maintained pain, and vasospastic or ischemic vascular disease

Sympathectomy for Pain and Hyperhidrosis: Based on the Breakfast Seminar of April 24, 2001, at the 69th Annual Meeting of the American Association of Neurological Surgeons, Toronto, Ontario, Canada.

Article

Neurosurgery Quarterly. 12(2):89-99, June 2002.
Wilkinson, Harold A.

Abstract:
Summary: Surgical resections of sympathetic ganglia from the thoracic, splanchnic, and lumbar area have been carried out for more than 100 years. In the past decade, neurosurgeons have become more interested in surgery on the sympathetic nervous system as less invasive techniques have been developed. Percutaneous radiofrequency and video-assisted endoscopic techniques have largely replaced open surgical thoracic sympathectomy. Lumbar and splanchnic sympathetic ablation is commonly done by percutaneous chemical techniques or, occasionally, by radiofrequency ablation, but the open techniques are still widely used. Sympathectomy is most widely employed for pathologic hyperhidrosis (especially the palmar component), sympathetically maintained pain, and vasospastic or ischemic vascular disease. The less invasive techniques are especially attractive for treating the sympathetically mediated cardiac diseases, including Prinzmetal angina, "syndrome X," and congenital long Q-T interval syndrome.

Surgical complications are usually manageable, but deaths have occurred (even with endoscopic techniques).

Endoscopic sympathetic block in the treatment

In this study, endoscopic sympathetic block was useful in reducing the symptoms of severe social phobia. Although the method is surgical and the effect hence mainly biological, the psychological symptoms of social phobia were also significantly reduced. The results are best if the main symptoms are blushing or palpitation, but even a smaller reduction in the other symptoms is important if it helps the patient to break his isolation.
Knowledge of the elimination of embarrassing physical symptoms in social situations helps the patient to expose himself to formerly impossible situations, and success in them also causes psychological symptoms to subside. But the relief of psychological symptoms may also be due to direct a biological effect of the operation on the anxiety-mediating areas in the nervous system. The only meaningful side effect is compensatory sweating of the trunk, but not even that is significant when modern surgical method are used.
Clamping is as good as bilateral cauterisation, and the results may be equally good with unilateral and bilateral clamping, but because there were only eight patients who had undergone a unilateral clamping procedure, the material is not sufficient to allow definite conclusions concerning that. The results remain unchanged over time, which shows that they were not due to a placebo effect. In the future, it is important to compare this treatment to traditional treatment in order to find out its place among the other, officially approved methods of treating social phobia.
http://informahealthcare.com/doi/abs/10.1080/08039480310000266