Paediatric Anaesthesia 1997 7: 159–161

Case reportAnaesthetic management of a child undergoingthoracoscopic removal of a lung cyst

TREVOR ARMSTRONG MB, BS ANDPAUL D. MARTIN MB, ChB, FRCA, DEAA

Department of Anaesthesia, Aberdeen Royal Hospitals, Foresterhill, Aberdeen AB9 2ZBScotland, UK.

SummaryThe anaesthetic management of a child undergoing video-assistedthoracoscopic resection of a large lung cyst is described. Inparticular, we discuss the prolonged postoperative stay, whichresulted from persistent pneumothorax, and his need for substantialanalgesia up to the twelfth postoperative day—which seemed noshorter than might have been expected following a thoracotomy.While other workers have claimed advantages with thoracoscopicoperations, in terms of reduced pain and morbidity, compared totraditional thoracotomy, we feel that one should be aware of thepotential for severe postoperative pain in these patients.

Keywords: postoperative analgesia; thoracoscopy

Case report Analgesia was provided by a total of 150 lg offentanyl (in 50 lg increments).

A healthy 45 kg, 12-year-old boy was admitted forA Mallinkrodt size 28 left-sided double lumen tube

elective thoracoscopic lung cystectomy. The lesion in was inserted and its position checked clinically beforehis left upper lobe was found following routine chest transfer to theatre and again immediately prior toradiography (Figures 1 and 2) during a previous surgery commencing. A large bore intravenousadmission for Henoch-Schonlein purpura. The boy cannula was inserted and an indwelling arterialwas asymptomatic and had no limitation in exercise line for continuous blood pressure monitoring wastolerance. established. Further intraoperative monitoring

Anaesthetic premedication comprised 10 mg consisted of ECG, pulse oximetry, FiO2, PeCO2 anddiazepam orally two h preoperatively and EMLA ventilator alarms.cream to the dorsum of both hands. Intravenous Surgery was performed through three 2–3 cmaccess was established and anaesthesia was induced incisions in the chest wall. Intraoperative progresswith sodium thiopentone, followed by atracurium was uneventful apart from two episodes of impairedand maintained with oxygen, air and isoflurane. ventilation. These were immediately detected by the

PeCO2 monitor before any fall in oxygen saturation.The cause was assumed to be movement of

Correspondence to: P. D. Martin, Department of Anaesthesia,the double lumen tube during instrumentalAberdeen Royal Hospitals, Foresterhill, Aberdeen AB9 2ZB,

Scotland, UK. manipulation of the cyst, as ventilation was

159 1997 Blackwell Science Ltd

160 T. ARMSTRONG & P.D. MARTIN

Figure 1Anteroposterior chest x-ray.

immediately restored by asking the surgeons torelease tension on the cyst.

Following completion of the surgery and insertionof a chest drain through the most lateral incision,the child was given a 50 mg diclofenac suppositoryand a total of 25 ml bupivicaine 0.25% plain wasinjected subcutaneously around the three incisions.

Figure 2Anaesthesia was discontinued and muscle relaxation Lateral chest x-ray.was reversed before an uncomplicated extubationand transfer to the recovery area—two h afterthe commencement of surgery. On recovering

At outpatient clinic review six weeks later, he wasconsciousness, he required 6 mg of morphinewell and the left lung was fully expanded.intravenously before returning to the ward.

Postoperative analgesia was continued using a PCAwith a 0.9 mg (0.02 mg·kg−1) bolus of morphine with Discussiona six min lockout and no background infusion.

The PCA was required for 48 h and was Thoracoscopic surgery has been performed for over70 years but its use in children was not reportedsupplemented with regular diclofenac (rectal then

oral) 3 mg·kg−1·day−1. Following withdrawal of the until 1976 (1). Since then this technique has gainedin popularity and has a number of indications (2).PCA, the regular diclofenac continued to be needed,

in conjunction with paracetamol until the twelfth There are claims of reduced pain and morbidity(3) as well as reduced cost (4) following thoracoscopicpostoperative day.

Recovery was further complicated by the procedures as opposed to those by conventionalthoracotomy. This was clearly not the case for thisdevelopment of a persistent left-sided pneumothorax

following the removal of the chest drain on the eighth patient. Despite initial fentanyl, rectal diclofenac andbupivicaine infiltration in theatre, as well aspostoperative day. A second drain was inserted and

remained for a further six days, delaying discharge intravenous morphine in the recovery area, herequired 21 mg of morphine in the first 12 huntil day 16.

1997 Blackwell Science Ltd, Paediatric Anaesthesia, 7, 159–161

THORACOSCOPIC REMOVAL OF LUNG CYST 161

postoperatively and a further 25 mg in the next 24 h. In summary therefore, we would caution againstThis was supplemented with regular diclofenac the assumption that pain and hospital stay are(3 mg·kg−1·day−1) and occasional paracetamol until reduced following thoracoscopic procedures. Wethe twelfth postoperative day. Had the operation recommend that anaesthetists remain prepared tobeen performed via a traditional thoracotomy, we treat these children as though they had had adoubt whether the wound length would have thoracotomy. We concur with Mulder in calling forexceeded the cumulative lengths of the three a ‘multicentre prospective study of pain controlthoracoscopy incisions. Moreover, we would have methods used after thoracoscopy’ (6).been more ready to use intercostal nerve blockadeor thoracic epidural analgesia assuming, perhapswrongly, that the pain would be more severe

Referencesfollowing thoracotomy. In addition, the episodes of1 Rodgers BM, Talbert JL. Thoracoscopy for the diagnosis ofimpaired intraoperative ventilation appeared to be

intrathoracic lesions in children. J Pediat Surg 1976; 11: 703–708.related to manipulation of the cyst with the2 Rodgers BM. Thorascopic procedures in children. Seminarsthoracoscopy instruments. We can only speculate Pediatr Surg 1993; Vol 2 No 3: 182–189.

whether these would have been avoided in an open 3 Rothenberg SS. Thoracoscopy in infants and children. SeminarsPediatr Surg 1994; Vol 3 No 4: 277–282.operation. A more serious complication was the

4 Hazelrigg SR, Nunchuck SK, Landreneau RJ, et al. Cost analysisdevelopment of a persistent pneumothorax, whichfor thoracoscopy; thoracoscopic wedge resection. Ann Thoracic

was attributed to a small air leak from the Surg 1993; 56: 633–635.stapled lung edge. This problem delayed discharge 5 Horswell JL. Anesthetic techniques for thoracoscopy. Ann of

Thoracic Surg 1993; 56: 624–629.and necessitated replacement of a chest drain,6 Mulder DS. Pain management principles in anesthesiaa manoeuvre known to increase analgesic

techniques for thoracoscopy. Ann Thoracic Surg 1993; 56: 630–632.requirements (5). It is unlikely that this complicationis any less common following thoracoscopicprocedures as opposed to traditional thoracotomy. Accepted 27 March 1996

1997 Blackwell Science Ltd, Paediatric Anaesthesia, 7, 159–161