PERIOPERATIVE CHALLENGES AND MANAGEMENT OF AN ADULT PATIENT WITH LARGE LEFT SIDED BOCHDALEK HERNIA PRESENTING WITH CO2 NARCOSIS: A CASE REPORT

Objective

Bochdalek hernia in adults may remain asymptomatic for years and may present acutely with respiratory or gastro-intestinal complications. Our patient with multiple comorbidities presented with CO2 narcosis and posed serious challenges in perioperative period.

Design and method

A 57-year-old gentleman presented with Type 2 respiratory failure (PCO2>100 mmHg) and obtundation in Emergency Room. He was known case of childhood Poliomyelitis with residual weakness (wheelchair bound), severe thoracolumbar kyphoscoliosis, obesity with obstructive sleep apnoea, diabetic, hypertensive, hypothyroid. Chest X-ray showed huge translucent area in left chest and tip of nasogastric tube in-situ. The HRCT confirmed large Bochdalek hernia(left). Patient was completely NIV (non invasive ventilation) dependent in ITU but still was hypercarbic (PCO2 70+ mmHg) and hypoxic(PO2 70mmHg in 70%FiO2) and hence surgical repair was planned. He had anticipated difficult airway (Mallampati 3, short neck, anterior larynx) with very poor functional capacity. Pre operative Echocardiography showed normal left and right ventricular function. Routine blood investigations were normal .Proper patient consent was obtained. In operation theatre standard ASA monitors were attached. After awake invasive lines (left20G radial line and right internal jugular 7.5Fr 5 lumen central venous line under local anaesthesia guided by live ultrasonography),he was preoxygenated with 100% O2 via NIV. Maximum SPO2 acquired with 100% Fio2 on NIV was 96%. After induction of general anaesthesia(Propofol,Fentanyl,Cisatracurium followed by Sevoflurane, Air, Oxygen) he was intubated electively with video-laryngoscope at single attempt. Then single lumen bronchial blocker was inserted to isolate left lung. Left thoracotomy and mesh repair of the huge diaphragmatic hernia was performed. Contents of the hernia were omentum ,stomach,mesentry and left colon.Part of left lower lung was found to be hypoplastic and wedge resection was done. Intercostal regional block and local infiltration to skin incision were administered. Patient got extubated next day but after extubation he had moderate hypercarbia and developed a pneumonia on day3 of post operative period. He was intubated again in ITU and eventually needing a tracheostomy to wean off ventilator. Tracheostomy was closed on day41. Eventually he was discharged on day 49.

Results and conclusions

Bochdalek hernia is congenital defect resulting from developmental failure of diaphragm located in the posterior insertion. Left posterolateral hernias are more frequent (85%) as compared to the right side (13%) and bilateral are (2%).Mostly Bochdalek hernia is diagnosed in children and in neonates and present clinical symptoms caused by associated pulmonary insufficiency. In adults asymptomatic Bochdalek hernia is rare (0.17% of the adult population).It tends to affect women(77%) mostly and predominantly appears on the right side(68%). A CT scan is the gold standard method providing an accurate assessment of the patients anatomy. Adult Bochdalek hernia usually presents as lung hypoplasia or gastrointestinal strangulation but our case was unique that it presented with CO2 narcosis. With multiple serious comorbidities, intraoperative challenges were steep including difficult airway, obesity, patient positioning due to kyphoscoliosis and maintaining one lung ventilation and post operative pain relief . Surgical repair is the option and anaesthetic challenges can be enormous in acute life-threatening presentations. Right intervention and management at right time is rewarding.