|Year : 2008 | Volume
| Issue : 4 | Page : 459
Acute Pulmonary Oedema after Removal of Sand Bag at the End of Open Cholecystectomy due to Unknown Cause
Sr. Specialist, Dept. of Anaesthesiology and Intensive Care, VMMC & SJH, New Delhi-29, India
|Date of Acceptance||30-Apr-2008|
|Date of Web Publication||19-Mar-2010|
Pramod Gupta, Dept. of Anaesthesiology and Intensive Care, VMMC & SJH, New Delhi-29
Source of Support: None, Conflict of Interest: None
Pulmonary oedema developes acutely during perioperative period and is usually due to unknown cause,but this life threatening complication if managed on time ,leads to rapid and full recovery. Here a case of 70 year old man is reported who developed acute pulmonary oedema after conclusion of surgery due to unknown cause.
Keywords: Open cholecystectomy-gall blader bridge-I.V.C, Compression-pulmonary oedema.
|How to cite this article:|
Gupta P. Acute Pulmonary Oedema after Removal of Sand Bag at the End of Open Cholecystectomy due to Unknown Cause. Indian J Anaesth 2008;52:459
|How to cite this URL:|
Gupta P. Acute Pulmonary Oedema after Removal of Sand Bag at the End of Open Cholecystectomy due to Unknown Cause. Indian J Anaesth [serial online] 2008 [cited 2018 Jun 18];52:459. Available from: http://www.ijaweb.org/text.asp?2008/52/4/459/60663
| Introduction|| |
Acute pulmonary edema has been described in relation to perioperative period. The etiology may be cardiac failure, fluid overload, airway obstruction, acid aspiration, gas embolism, anaphylactic reaction, higher oxides of nitrogen and reaction to blood and blood products  .
Cardiogenic type is the commonest cause of pulmonary oedema in the clinical setting  . In this case pulmonary oedema occurred at the conclusion of open cholecystectomy following sand bag removal. Clinical findings in this case attribute towards cardiogenic pulmonary oedema after exclusion of all other causes of pulmonary oedema.
| Case report|| |
A 70-yr-old male, weighing 60kg was scheduled for an open cholecystectomy. Patient was otherwise fit and was not taking any regular medication. There were no symptoms pertaining to cardio- respiratory or central nervous systems. The preoperative ECG showed LBBB. Chest X ray was normal. Echo showed decreased left side wall movement with ejection fraction of 55%. Rest of the investigations were within normal limits.
Patient was premedicated with tablet diazepam 5 mg oral, night before the day of operation. Patient's preoperative pulse rate, BP, RR , SpO 2 were 75/ min, 150/86 mm Hg, 14/ min and 97% respectively.
General anaesthesia was induced with morphine 4.5 mg, propofol 100 mg and vecuronium 6mg iv. Trachea was intubated with no.(8) cuffed orotracheal tube. Anaesthesia was maintained with O 2 :N 2 O (30:70), Isoflurane 0.4% and vecuronium top up doses. In order to facilitate the surgical exposure sandbag of dimensions 12"x6"x6" was placed , bilaterally under the lower half of the rib cage. Surgery was done uneventfully under general anaesthesia and all parameters i.e, pulse, BP, SpO 2 , EtCO 2 were continuously monitored and were within normal limts throughout the operation.
The surgery lasted for 1½ hours, during which 1300 ml of crystalloid was infused. At the conclusion of the surgery before reversal sand bag was removed suddenly without informing anaesthetists , following which SpO 2 decreased from 97% to 78% and pulse increased to 130/min. There was no change in the ECG pattern and BP was 130/80 mm Hg. After one minute of this event, pink frothy fluid was seen in Bains circuit. On auscultation bilateral fine crepts were present. Patient was given morphine 4.5 mg, vecuronium 2 mg and frusemide 80 mg intravenously. Patient was ventilated with 100% oxygen . Patient was catheterized and urine output was 400 ml. Before shifting the patient to ICU, CVP line was secured which showed the reading of 9 cm of water. Patient gradually improved over a period of 20 min i.e, SpO 2 became 97%, pulse rate decreased to 80/ min. However patient's systolic BP became 90 mmHg. Patient was transferred to ICU on dopamine and ventilatory support for further management.
Post operatively, when X ray chest was done in I.C.U. bilateral symmetrical hilar opacities were seen this finding being supportive of pulmonary oedema of cardiac origin, enzyme studies were done to rule out MI and were found to be within normal limits. CVP was also well maintained at 8 cm of water. Patient was ventilated for 2 days and was extubated on third day . Patient was discharged from the hospital on the seventh day successfully.
| Discussion|| |
Acute pulmonary oedema has got high incidence during perioperative period and it is of importance because it can acutely affect gas exchange tremendously. Guyton and Hall studied the effect of elevated left atrial pressure and decreased plasma proteins on the development of pulmonary oedema and they found that left atrial pressure greater than 25 mmHg causes fluid accumulation in lungs  .
If the oedema is of cardiac origin, then the fluid is pink and frothy due to rupture of congested pulmonary capillaries which is not seen in oedema due to other causes. Also intravascular pressure increases due to neurogenic vasoconstriction and causes acute oedema. This vasoconstriction is abolished by morphine injection  .
Incidence of bundle branch block increases with age, although myocardium is diseased but patient may be asymptomatic  . In a patient with LBBB, left ventricle has delayed contraction and relaxation as compared to right ventricle. As a result of this, there is an alteration in the diastolic filling time  .
In our patient during operation a sand bag of the dimensions 12"×6"×6" was placed bilaterally below the lower rib cage to improve access to gall bladder.
This position arches the spine and leads to pressure on the major vessels thereby reducing their caliber and blood flow is markedly impeded in thin walled IVC  .
Ultrasound study was carried out, to find the caliber of IVC after the sand bag placement and after its sudden removal. The caliber of IVC in supine position was 19mm ×11mm [Figure 1] and after bilateral sand bag placement it became 13mm × 5.7mm [Figure 2] and after its sudden removal it was 22mm ×13mm[Figure 3]. Unilateral sand bag placement of the dimensions 4"×3"×2" did not affect the caliber of IVC[Figure 4].
In this patient we speculate, that sudden removal of sand bag might have relieved the compression of IVC and this in turn lead to sudden increase in venous return to right heart and overloading of left atrium which was transmitted back to the pulmonary circulation leading to acute pulmonary oedema  .
Knowledge and planning are important key ingredients for safe positioning of surgical patients on the operating table. Positioning should always be done slowly and it demands proper monitoring throughout. To avoid disastrous consequences proper precautions should be taken for safe positioning. This case report may give new direction towards the mechanisms of acute pulmonary oedema and recommendation of unilateral sand bag placement for better exposure without compresing I.V.C.C.
| References|| |
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]