Major pneumothorax during pediatric cardiac MRI procedure under general anesthesia: step-by-step analysis and importance of a well-known environment and material

Abstract

Background To perform step-by-step analysis of the different factors (material, anesthesia technique, human, and location) that led to major pneumothorax during an infrequent pediatric cardiac MRI and to prevent its occurrence in the future. Anesthesia equipment used in a remote location is often different than those in operating rooms. For magnetic resonance imaging (MRI), ventilation devices and monitors must be compatible with the magnetic fields. During cardiac MRI numerous apneas are required and, visual contact with the patient is limited for clinical evaluation. Anesthesia-related barotrauma and pneumothorax are rare in children and the first symptoms can be masked. Case Presentation A 3-year-old boy with atrial septal defect (ASD) and suspicious partial anomalous pulmonary venous return was anesthetized and intubated to perform a follow up with MRI. Sevoflurane maintenance and ventilation were performed using a circular CO2 absorber device, co-axial circuit, and 500 mL pediatric silicone balloon. Apneas were facilitated by Alfentanyl boluses and hyperventilation. A few moderated desaturations occurred during the imaging sequences without hemodynamic changes. At the end of the MRI, facial subcutaneous emphysema was observed by swollen eyelids and crackling snow neck palpation. A complete left pneumothorax was diagnosed by auscultation, sonography examination, and chest radiograph. Pneumo-mediastinum, -pericardium and -peritoneum were present. A chest drain was placed, and the child was extubated and transferred to the pediatric intensive care unit (PICU). Despite the anesthesiologist’s belief that PEEP was minimal, critical analysis revealed that PEEP was maintained at a high level throughout anesthesia. After the initial barotrauma, repeated exposure to high pressure led to the diffusion of air from the pleura to subcutaneous tissues and mediastinal and peritoneal cavities. Equipment check revealed a functional circular circuit; however, the plastic adjustable pressure-limiting valve (APL) closed within the last 30° rotation. The balloon was found to be more rigid and demonstrated significantly reduced compliance. Conclusions Anesthetists require proficiency is using equipment in non-OR locations and this equipment must be properly maintained and checked for malfunctions. Controlling the human factor risks by implementing checklists, formations, and alarms allows us to reduce errors. The number of pediatric anesthesia performed routinely appeared to be essential for limiting risks and reporting our mistakes will be a benefit for all who care about patients.