K
Hussey and R Jeffrey
Cardiothoracic
Surgical Unit, Aberdeen Royal Infirmary, Scotland
Corresponding
Author:
SMJ 2006 52(1): 55
Abstract
A 53 year old male
presented with a type I acute aortic dissection managed surgically, with
placement of a tube graft and aortic valve re-suspension procedure. We present a
complication associated with the adjunct cerebral protection employed, in the
form of an acute cold injury in the right occipital region secondary to packing
the head in ice.
Introduction
The cerebral
complications of circulatory arrest are well recognised. In our centre we have
employed deep hypothermic circulatory arrest to permit construction of the
distal anastomosis in a bloodless surgical field, with retrograde cerebral
perfusion employed as an additional means of cerebral protection. As an adjunct
we have also routinely packed the head in ice as described by Steyn et al.1
Case Report
A 53 year old male
presented as an emergency with shortness of breath secondary to acute aortic
valve regurgitation and pulmonary oedema. Pre-operative investigation in the
form of transoesphageal echocardiography and CT angiography revealed a type I
aortic dissection and as such he underwent emergency surgery. His pre-operative
logistic euroscore was 11.
The procedure
involved the placement of an aortic tube graft with aortic valve re-suspension.
Deep hypothermic circulatory arrest was employed and as an adjunct to cerebral
protection the head was packed in ice. The patient spent 137 hours in the
intensive care unit prior to transfer to the ward. In the immediate
post-operative period he complained of left sided weakness and a CT scan of his
brain subsequently revealed an infarct involving the posterior half of the right
middle cerebral artery territory and a smaller area of infarction in the left
parietal lobe superiorly.
During this time he was noted to have an erythematous, dusky area in the left occipital region (figure 1 and 2), which represented thermal injury secondary to the patient’s head being packed with ice. This was a mixed depth dermal injury and was managed conservatively, ultimately resolving with no significant scarring.
After a hospital
stay of 12 days the patient was discharged from the cardiothoracic unit,
subsequently making a good recovery, with no significant neurological deficit.
The patient was discharged from cardiothoracic follow-up after twelve months.
Discussion
Tissues are more
resistant to cold injury than to heat injury and the associated inflammatory
reactions tend not to be as marked. As such the assessment of depth of injury is
much more difficult, however in this case our initial assumption was that this
injury represented a mixed depth dermal injury or ‘second-degree’ frostbite.
Acute cold injury
is essentially a spectrum of disease classified according to severity of
clinical aspect and evolution. The initial injury is characterised by pallor or
transitory cyanosis then by erythema followed by spontaneous and complete
healing in the majority of cases. The pathophysiological response is the result
of peripheral vasoconstriction with a reduction in the capillary perfusion
gradient and the development of tissue hypoxia and acidosis. Thereafter, during
re-warming there is reactive hyperaemia, which facilitates the movement of a
cellular exudate into the interstitium with further disruption of the
microcirculation. There is initiation of the inflammatory cascade with
reperfusion injury.
We had not come
across this complication before with this method of cerebral protection.
However, there are a number of case reports with similar acute cold injuries
reported in the literature.2, 3 In this case the patient was managed
successfully conservatively. There is some evidence in the literature, which
suggests that ice or other ‘cold packs’ should not be allowed to come in
direct contact with the skin, or applied for more than fifteen minutes at a
time.3, 4 This experience will influence our future practice and
should be borne in mind by those employing this adjunct method of cerebral
protection.
References
1.
Steyn RS, Jeffrey RR. An adjunct to cerebral protection during
circulatory arrest. European Journal of Cardiothoracic Surgery 1993; Vol 7:
443-444
2.
Keskin M, Torsun Z, Duymaz A, Savac N. Frostbite injury due to improper
use of an ice pack. Annals of Plastic Surgery 2005 Oct; 55(4): 437-8
3.
Graham CA, Stevenson J. Frozen chips: an unusual cause of severe
frostbite injury. British Journal of Sports Medicine 2000; 34: 382-3
Stevens DM, D’Angelo JV. Frostbite due to improper use of frozen gel pack. New England Journal of Medicine 1978; 299:1415