Title: Ultrasonography: an uncommon way to diagnose a pneumothorax 

Background: The role of ultrasonography in the anesthesiology daily practice does not stop in the locoregional techniques. Nowadays, this tool has a massive importance, including the intraoperative diagnosis of several clinical entities1. The authors describe the clinical case of iatrogenic pneumothorax (PT) that happened during laparoscopic surgery, which, after clinical suspicion, was diagnosed by ultrasonography.

Case report: Male, 64 years old, classified as ASA II (obesity and diverticulosis). The patient was submitted to a laparoscopic total gastrectomy due to adenocarcinoma in the lesser curvature of the stomach under combined anesthesia (thoracic epidural and, afterwards, general anesthetic induction), uneventful. Patient was monitored with standard ASA and BIS. 160 minutes after incision, the patient desaturated progressively (O2 at 100%: 91%), with no vesicular murmur on the left hemifield on pulmonary auscultation. The surgical team pointed out the possibility of iatrogenic stomach laceration, fact not confirmed after instillation of methylene blue. Thus, we confirmed the correct position of the endotracheal tube by fibroscopy. Clinical suspicion of iatrogenic pneumothorax was strong and we further confirmed it by ultrasonography. A thoracic drain was inserted, uneventful. No significant complications were noted in the postoperative period.
Discussion: Pneumothorax is one of the most frequent complications in laparoscopic surgery, with described incidence between 0,01 and 3%. The use of ultrasound on its diagnosis gained significance due to the high portability, specificity (100%) and sensitivity (95%), image quality and generalized access by the anesthetists, which allows a quick diagnosis and subsequent treatment1. The presence or absence of typical sonographic signs permit the pneumothorax diagnosis, such as stratosphere sign on M mode, immobility of the pleura with respiratory movements and loss of comet tail sign. In this specific area, the literature states that the PT diagnosis can be done with high level of reliability, regardless the previous experience with ultrasonography.

References: 1 Terwaki A et al; Ultrasound for the anesthesiologist: present and future; The Scientific World Journal; vol 2013 (2013)

Learning points: Due to the above described, the authors aim to reveal and broaden the limits of this technic in anesthesiology daily practice during the whole perioperative period.