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CASE REPORT
Year : 2008  |  Volume : 52  |  Issue : 4  |  Page : 459 Table of Contents     

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 Acceptance30-Apr-2008
Date of Web Publication19-Mar-2010

Correspondence Address:
Pramod Gupta
Pramod Gupta, Dept. of Anaesthesiology and Intensive Care, VMMC & SJH, New Delhi-29
India
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Source of Support: None, Conflict of Interest: None


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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 Oct 18];52:459. Available from: http://www.ijaweb.org/text.asp?2008/52/4/459/60663


   Introduction Top


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 [1] .

Cardiogenic type is the commonest cause of pul­monary oedema in the clinical setting [2] . 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 Top


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 Top


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 [3] .

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 [2] .

Incidence of bundle branch block increases with age, although myocardium is diseased but patient may be asymptomatic [4] . 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 [5] .

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 [6] .

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 [6] .

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 Top

1.Fisher M, Stevenson I F. Unexplained acute membrane pulmonary oedema related to anaesthesia. Anaesthesia Intensive Care 1986;14:29-31.  Back to cited text no. 1      
2.Hurley J V. Current views on the mechanisms of pulmo­nary oedema. Journal of Pathology 1978;125:2:71-72.  Back to cited text no. 2      
3.Hsuy H, Kau S J, Lee R P, et al. Acute pulmonary oedema induced by various rare causes and possible mecha­nisms. Clin Sci 2003;104:259-264.  Back to cited text no. 3      
4.Eriksson P, Hansson P O, Eriksson H et al. Bundle branch block in a general male population. Circulation 1998;98:2494-2500.  Back to cited text no. 4      
5.Arines C L, Bashore T M, et al. Functional abnormali­ties in isolated left bundle branch block. Circulation 1989;79:845-853.  Back to cited text no. 5      
6.Martin J T, Warner M A. Positioning in anesthesia and surgery. W.B. Saunders Co 1997.  Back to cited text no. 6      


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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