Background:Idiopathic Severe Scoliosis (ISS) has a prevalence < 0.1%. Surgical correction is complex and may require multiple discectomy trough anterior thoracotomy with one lung ventilation (OLV) and extended posterior instrumentation under evoked potentials monitoring in a lung restricted patient. Our unique case highlights how pulmonary complications related to surgical and anaesthetic approach
superimposed on severely restricted lungs can be successfully managed with a multimodal and multidisciplinary approach in perioperative period.
Case Report:Fifteen year old female, ASA III, with a severe thoracolumbar scoliosis and restrictive lung disease, Cobbˋs angle of 120º, proposed for antero-posterior scoliosis correction. Total intravenous anaesthesia was administered with propofol, remifentanil and ketamine, with a left double lumen tracheal tube insertion, confirmed with fiberscope. While on left OLV, patient developed severe bronchospasm, with important oxygenation and ventilation impairment. Ongoing ketamine, inhaled bronchodilators and corticoid therapy were ineffective, so sevoflurane targeting MAC 0.5, deep muscular relaxation, and pressure controlled ventilation (PCV) followed with favourable outcome. Upon transition to posterior approach right sided chest tube was inserted and double lumen tube was replaced by a reinforced tracheal tube. During spinal distraction, surgeon reported a left side pleural rupture. Surgical glue was applied and the left iatrogenic pneumothorax didn’t translate in ventilatory or hemodynamic instability. After an 11 hours’ procedure, patient was extubated and transferred to the ICU without immediate complications. After two days she developed a left total pneumothorax which was managed with insertion of a chest tube without further complications. After 20 days she was discharged home.
Discussion:OLV in the setting of restrictive disease is a demanding task. In our patient severe bronchospasm and a second iatrogenic pneumothorax ensued and a multimodal strategy with PCV, multiple intravenous and inhalatory drugs and a close communication with surgical team were the key for the successful ventilatory management.
Learning points:Multiple surgical and anaesthetic complications can occur during OLV and in the postoperative period of ISS correction. Success on ventilation management requires a multimodal approach and close teamwork. Careful post-operative planning may minimize potentially catastrophic complications.

11 / ONE LUNG VENTILATION PITFALS ON SEVERE THORACOLUMBAR SCOLIOSIS SURGERY