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Injury of diaphragm during surgery — Clinical Guidelines

Overview

Diaphragmatic injury during surgery, particularly in pediatric cardiac and thoracic procedures, represents a significant complication that can severely impact postoperative recovery and outcomes. This condition often manifests as diaphragmatic paralysis (DP), leading to respiratory compromise, prolonged intensive care unit (ICU) stays, and increased morbidity and mortality. Neonates and infants undergoing cardiac surgeries are particularly vulnerable, with an incidence ranging from 2.6% to higher in specific procedures like bidirectional Glenn, arterial switch operations, and Blalock-Taussig-Thomas shunt 1 4. Early detection and appropriate management, including diaphragmatic plication, are crucial for improving patient outcomes. Understanding the risk factors, diagnostic approaches, and management strategies is essential for clinicians to optimize care and reduce complications in daily practice 1 4.

Pathophysiology

Diaphragmatic injury during surgery typically results from inadvertent trauma to the muscle fibers or nerves innervating the diaphragm, often due to direct surgical manipulation or retraction forces. In pediatric cardiac surgeries, the delicate nature of the infant diaphragm and the proximity of surgical sites to the diaphragm increase the risk of injury 1. The injury can disrupt the normal mechanical function of the diaphragm, leading to impaired respiratory mechanics such as reduced lung compliance and ventilation efficiency. Additionally, nerve damage can cause denervation atrophy, further compromising diaphragmatic function 8. These pathophysiological changes can lead to respiratory insufficiency, characterized by hypoventilation, atelectasis, and potential hypoxemia, necessitating prolonged mechanical ventilation and ICU support 8.

Epidemiology

The incidence of diaphragmatic paralysis following pediatric cardiac surgery ranges from 2.6% to higher, depending on the specific surgical procedures involved 1 4. Neonates and infants under 4 weeks of age undergoing complex cardiac surgeries (Risk Adjustment for Congenital Heart Surgery grades 5-6) are at significantly higher risk 4. Geographic and sex-specific distributions are not extensively detailed in the provided sources, but age and surgical complexity emerge as key risk factors. Trends over time suggest that advancements in surgical techniques and perioperative care have not eliminated this complication, highlighting the persistent need for vigilance 1 4.

Clinical Presentation

Patients with diaphragmatic injury often present with nonspecific symptoms initially, including respiratory distress, tachypnea, and cyanosis, particularly in pediatric populations 1 7. In neonates and infants, delayed recovery from anesthesia, prolonged mechanical ventilation requirements, and signs of respiratory failure are critical red flags 1. Older children and adults undergoing thoracic surgeries may exhibit more subtle symptoms like dyspnea, abdominal pain, and vomiting, especially if the injury is right-sided where diagnosis can be delayed due to less obvious clinical signs 7. Early recognition is crucial to prevent long-term respiratory complications.

Diagnosis

The diagnostic approach for diaphragmatic injury involves a combination of clinical assessment, imaging, and functional tests. Key diagnostic criteria include:

Clinical Assessment: Signs of respiratory compromise, prolonged mechanical ventilation, and delayed recovery post-surgery.

Imaging:

- Chest X-ray: May show elevated hemidiaphragms, atelectasis, or other respiratory abnormalities. - CT Scan: Provides detailed visualization of diaphragmatic integrity and can help identify tears or hernias. - Ultrasound: Particularly useful in neonates, assessing diaphragmatic excursion and identifying paralysis.

Functional Tests:

- Diaphragmatic Excursion Measurement: Using anatomical M-mode ultrasound for accurate assessment post-cardiac surgery 6. - Electromyography (EMG): To evaluate nerve function and muscle activity, though less commonly used in acute settings.

Differential Diagnosis:

- Post-operative Atelectasis: Differentiates based on imaging and clinical progression. - Pneumonia: Clinical symptoms and microbiological evidence help distinguish. - Respiratory Muscle Weakness: Assess through respiratory function tests and exclude other causes of muscle weakness 8.

(Evidence: Moderate) 6 8

Management

Initial Management

Supportive Care: Initiate mechanical ventilation with appropriate settings to ensure adequate oxygenation and ventilation.

Monitoring: Continuous monitoring of respiratory parameters, including oxygen saturation, tidal volume, and respiratory rate.

Definitive Management

Diaphragmatic Plication: Indicated for significant paralysis to improve respiratory function and reduce mechanical ventilation duration.

- Surgical Technique: Performed via thoracotomy or laparoscopy, involving plication of the paralyzed hemidiaphragm to approximate normal diaphragm function. - Timing: Early intervention (within days to weeks post-surgery) is recommended to prevent long-term respiratory complications 1 4.

Pharmacological Support

Bronchodilators: To reduce airway resistance and improve ventilation, particularly if there is associated bronchospasm.

Steroids: Consider in cases where inflammation contributes to diaphragmatic dysfunction, though evidence is limited 8.

Contraindications

Severe Co-morbidities: Advanced cardiopulmonary disease or other critical conditions that may preclude surgical intervention.

Poor Prognosis: Cases where the overall prognosis is poor despite intervention.

(Evidence: Moderate) 1 4 8

Complications

Prolonged Mechanical Ventilation: Common complication requiring extended ICU stays.

Respiratory Infections: Increased risk of pneumonia and other respiratory tract infections.

Pulmonary Complications: Atelectasis, hypoxemia, and long-term respiratory insufficiency.

Gastrointestinal Issues: Postoperative intussusception and other gastrointestinal complications, particularly noted in pediatric cases 7.

Refer patients with persistent respiratory failure or recurrent infections to pulmonology and thoracic surgery specialists for further evaluation and management 7.

Prognosis & Follow-up

The prognosis for patients with diaphragmatic injury varies based on the severity of paralysis and timeliness of intervention. Early diagnosis and effective management, including diaphragmatic plication, can significantly improve outcomes, reducing ICU stays and improving long-term respiratory function 1 4. Prognostic indicators include the extent of diaphragmatic involvement, age at intervention, and overall surgical complexity. Recommended follow-up intervals include:

Short-term (1-3 months post-surgery): Regular clinical assessments, pulmonary function tests, and imaging to monitor recovery.

Long-term (6-12 months and beyond): Periodic evaluations to assess respiratory health, growth parameters in pediatric patients, and overall quality of life.

(Evidence: Moderate) 1 4

Special Populations

Pediatrics

Risk Factors: Neonates and infants undergoing complex cardiac surgeries are at higher risk.

Management Considerations: Early intervention with diaphragmatic plication is crucial due to the critical nature of respiratory support in young children.

Elderly

Increased Comorbidities: Higher prevalence of underlying respiratory and cardiovascular conditions complicates diagnosis and management.

Care Approach: Tailored supportive care with close monitoring for complications like pneumonia and atelectasis.

(Evidence: Moderate) 1 4 8

Key Recommendations

Early Identification and Monitoring: Regularly assess respiratory function post-surgery, especially in high-risk patients (Evidence: Moderate) 1 6

Immediate Imaging: Utilize chest X-ray and CT scans for early detection of diaphragmatic injury (Evidence: Moderate) 1 6

Consider Diaphragmatic Plication: For significant paralysis, early surgical intervention improves outcomes (Evidence: Moderate) 1 4

Supportive Mechanical Ventilation: Optimize ventilator settings to prevent secondary lung injury (Evidence: Moderate) 8

Close Postoperative Monitoring: Frequent assessments for signs of respiratory complications and infections (Evidence: Moderate) 7

Pediatric Considerations: Prioritize early intervention in neonates and infants due to higher vulnerability (Evidence: Moderate) 1 4

Multidisciplinary Approach: Involve pulmonology and thoracic surgery specialists for complex cases (Evidence: Expert opinion) 7

Long-term Follow-up: Schedule regular pulmonary function tests and clinical evaluations to monitor recovery (Evidence: Moderate) 1 4

Risk Factor Assessment: Evaluate surgical complexity and patient comorbidities preoperatively to tailor management strategies (Evidence: Moderate) 4

Use Advanced Imaging Techniques: Employ anatomical M-mode ultrasound for precise diaphragmatic excursion measurements post-surgery (Evidence: Moderate) 6

References

1 Elgayar MM, Negm MA, Nasr EG, Abdullah H, Hamed S, Honsy H. Evaluating Diaphragmatic Paralysis After Pediatric Cardiac Surgery and the Role of Plication in Outcome Improvement: Insights From a Single-Center Experience. World journal for pediatric & congenital heart surgery 2025. link 2 Chen M, Huang Y, Hu J, Jia L, Wu Y, Feng J et al.. Risk factors for diaphragmatic injury in subxiphoid video-assisted thoracoscopic surgery. Surgical endoscopy 2024. link 3 Dittberner FA, Ladegaard L, Licht PB. A Diaphragmic Traction Suture Increases Pleural Cavity Volume and Surgical Field Overview During Video-Assisted Thoracoscopic Surgery. World journal of surgery 2022. link 4 Foster CB, Cabrera AG, Bagdure D, Blackwelder W, Moffett BS, Holloway A et al.. Characteristics and outcomes of children with congenital heart disease needing diaphragm plication. Cardiology in the young 2020. link 5 de Cesare N, Trevisan C, Maghin E, Piccoli M, Pavan PG. A finite element analysis of diaphragmatic hernia repair on an animal model. Journal of the mechanical behavior of biomedical materials 2018. link 6 Pasero D, Koeltz A, Placido R, Fontes Lima M, Haun O, Rienzo M et al.. Improving ultrasonic measurement of diaphragmatic excursion after cardiac surgery using the anatomical M-mode: a randomized crossover study. Intensive care medicine 2015. link 7 Karnak I, Senocak ME, Tanyel FC, Büyükpamukçu N. Diaphragmatic injuries in childhood. Surgery today 2001. link 8 Siafakas NM, Mitrouska I, Argiana E, Bouros D. Effects of surgery on the function of the respiratory muscles. Monaldi archives for chest disease = Archivio Monaldi per le malattie del torace 1999. link

Injury of diaphragm during surgery