Case report 1 Life threatening subcutaneous emphysema following surgical repair of tracheocutaneous fistula VIRENDER KUMAR MOHAN MD, DA MD, DA , LOKESH KASHYAP MD DA MD DA AND SANJAY VERMA MD MD Department of Anaesthesiology and Intensive Care, All India Institute of Medical Sciences (AIIMS), New Delhi, India Summary A 9-year-old male child posted for closure of tracheocutaneous fistula developed extensive subcutaneous emphysema resulting in acute respiratory distress immediately after transfer to recovery room. The clinical management, precautions and other complications of closure of tracheocutaneous fistula are discussed. Keywords: paediatric; tracheostomy; tracheocutaneous fistula; sub- cutaneous emphysema Introduction Development of tracheocuaneous fistula (TCF) is a complication of tracheostomy that may be trouble- some in patient’s care and may exacerbate respirat- ory disease. Recurrent aspiration, infection, poor cough, skin irritation and cosmetic and social non- acceptance are common problems associated with persistent TCF. Incidence of TCF ranges from 3.3 to 42% (1). Closure of the fistula is ideal treatment of TCF, but life-threatening complications after surgical repair do occur. Common problems associated with surgical closure of fistula are pneumothorax, respir- atory compromise and development of cervical aerocele (2,3). We report a case of TCF posted for surgical closure of TCF that developed life-threaten- ing extensive subcutaneous emphysema resulting in respiratory distress necessitating reopening of the tracheostomy. Case report A 9-year-old 23-kg male child a follow-up case of tracheo-laryngeal papilomatosis with TCF was pos- ted for surgical closure of fistula. His preoperative evaluation showed normal larynx, normal vocal cord movements with no evidence of subglottic stenosis. He was premedicated with oral diazepam 5 mg on the day of surgery. In operating room routine monitoring was started. Anaesthesia was induced with thiopentone sodium (5 mg®kg )1 ) and fentanyl (2 lg®kg). Vecuronium bromide (0.1 mg®kg )1 ) was used to facilitate the tracheal intubation with 5 mm PVC cuffed tracheal tube. We found little resistance at the level of tracheal opening but were able to insert the tracheal tube with little force. Anaesthesia was maintained with oxygen–nitrous oxide–halothane (0.5–1%). Lungs were mechanically ventilated with tidal volume (10 ml®kg )1 ) and rate (16 min )1 ) to maintain endtidal CO 2 between 35 and 45 mmHg. The TCF closure was performed in three layers and lasted for 90 min, and was uneventful. Neuromus- cular blockade was reversed with neostigmine Correspondence to: Dr Virender K. Mohan, F-92, Ansari Nagar (West), New Delhi-110029, India (email: dr_vkmohan@yahoo. com). Paediatric Anaesthesia 2003 13: 339–341 Ó 2003 Blackwell Publishing Ltd 339