- Letter to the Editor
- Open Access
Subcutaneous emphysema and ultrasound sonography
https://doi.org/10.1186/2052-0492-1-8
© Kubodera et al.; licensee BioMed Central Ltd. 2013
- Received: 2 August 2013
- Accepted: 16 October 2013
- Published: 27 November 2013
Abstract
Subcutaneous emphysema is not a rare complication in intensive care unit patients. Recently, ultrasound guidance for central venous puncture is becoming popular; however, the information on imaging for subcutaneous emphysema is limited. We encountered a patient complicated with severe pneumomediastinum and subsequent subcutaneous emphysema. The catheter replacement was attempted, and we examined the visuality of cervical vessels using ultrasound sonography before the intervention. Internal jugular vein itself was observed despite of subcutaneously migrated air bubble; however, the range of ultrasound image was limited, and the relationship between the vessel and the adjacent tissue was unclear.
Keywords
- Subcutaneous emphysema
- Ultrasound sonography
- Central venous catheterization
Findings
Subcutaneous emphysema is not a rare complication in patients admitted to intensive care unit and received mechanical ventilation as well as with pneumomediastinum [1]. High positive end-expiratory pressure leading to excess airway strain would be one of the risk factors of the complications [2]. Patients requiring high airway pressure might be severely ill and need many medical interventions including central venous catheterization.
Recently, ultrasound guidance for central venous puncture is strongly recommended [3] and is sometimes required as a mandatory procedure [4] in hospitals. Ultrasound sonography is a useful and powerful tool for detecting the deep vein distinguished from the artery using the color Doppler imaging methods [5]. Moreover, sonography enables us to confirm the site of puncture for monitoring the spatial relationships between the venous and the needle during the puncture through the real-time imaging [6]. One of the important factors for complicating the ultrasound-guided central venous catheterization is subcutaneous emphysema as ultrasound barrier [7]. Absolute difference of acoustic impedance between the aqueous tissue and migrated air causing emphysema occludes the scattering of ultrasound signals and prevents from composing the image of deep body structures. Verniquet and Katel [7] reported the scanning image of the patient with subcutaneous emphysema; however, there is scarce information of the ultrasound images in a literature for the patient with subcutaneous emphysema.
The chest X-ray and CT findings of the patient. Massive emphysema was observed in the neck, chest, and mediastinum.
Ultrasound images. Left: The ultrasound image of the patient's neck in coronal view was demonstrated. The identification of both jugular vein and carotid artery was barely possible in spite of many subcutaneous ultrasound barriers by emphysema. Right: The ultrasound image in sagittal view was demonstrated. The jugular vein was feasibly observed; however, the carotid artery that is a relatively deep structure could not be identified. JV jugular vein, CA carotid artery, AS acoustic shadow by air.
More and more information are gathered for reliable and safety catheterization using ultrasound guidance in the area of anesthesiology and intensive care medicine. We should continue to accumulate information of a plenty of images through daily clinical settings not only for normal subjects but also for complicated cases.
Authors’ information
TK is a staff in the Emergency Department of Ogaki Municipal Hospital. He worked in the Department of Emergency and Critical Care Medicine, Nagoya University Graduate School of Medicine. YUA is an assistant professor in the Department of Emergency Medicine and the corresponding author of this letter. TH and TE are assistant professors of Emergency and Critical Care Medicine and consultants of ultrasound sonography. AN is an assistant professor of Emergency and Critical Care Medicine and a consultant of ultrasound echocardiography. NM is a professor and Chairman of Emergency and Critical Care Medicine.
Declarations
Authors’ Affiliations
References
- Lai JI, Lin PC, Wang WS, Chang SC, Lai YC: Barotrauma related extensive pneumothorax, pneumomediastinum, and subcutaneous emphysema in a patient with acute respiratory distress syndrome with low tidal volume. Postgrad Med J 2010, 86: 567-568. 10.1136/pgmj.2010.102368View ArticlePubMedGoogle Scholar
- Boussarsar M, Thierry G, Jaber S, Roudot-Thoraval F, Lemaire F, Brochard L: Relationship between ventilatory settings and barotrauma in the acute respiratory distress syndrome. Intensive Care Med 2002, 28: 406-413. 10.1007/s00134-001-1178-1View ArticlePubMedGoogle Scholar
- Tokumine J, Lefor AT, Yonei A, Kagaya A, Iwasaki K, Fukuda Y: Three-step method for ultrasound-guided central vein catheterization. Br J Anaesth 2013, 110: 368-373. 10.1093/bja/aes381View ArticlePubMedGoogle Scholar
- Neustein SM: Mandating ultrasound usage for internal jugular vein cannulation. Can J Anaesth 2010, 57: 868-869. 10.1007/s12630-010-9351-zView ArticlePubMedGoogle Scholar
- Walther ND, Auyong DB: Subclavian artery and vein transposition has implications for regional anesthesia and subclavian vein catheter insertion. Anesth Analg 2012, 115: 211-212. 10.1213/ANE.0b013e3182572983View ArticlePubMedGoogle Scholar
- Adachi YU, Tuzuki M, Matsuda N: Is it constantly possible to penetrate only the anterior vessel wall against hydrostatic strain? Crit Care Med 2012, 40: 2534-2535.View ArticlePubMedGoogle Scholar
- Verniquet A, Kakel R: Subcutaneous emphysema: ultrasound barrier. Can J Anaesth 2011, 58: 336-337. 10.1007/s12630-010-9435-9View ArticlePubMedGoogle Scholar
Copyright
This article is published under license to BioMed Central Ltd. This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.