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CASE REPORT
Year : 2009  |  Volume : 53  |  Issue : 4  |  Page : 475-477 Table of Contents     

Unilateral Dependant Pulmonary Edema During Laparoscopic Donor Nephrectomy: Report of Three Cases


1 Assistant Professor, Department of Anesthesiology IKDRC, Ahmedabad, India
2 Prof. & Head, Department of Urology and Transplantation Surgery, Ahmedabad, India

Date of Web Publication3-Mar-2010

Correspondence Address:
Manisha Modi
Department of Anesthesiology, Instititue of Kidney Diseases and Research Centre, Institute of Transplantation Sciences, Civil Hospital Campus, Asarwa,Ahmedabad-380 016
India
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Source of Support: None, Conflict of Interest: None


PMID: 20640211

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Unilateral pulmonary edema of the dependant lung was observed in three patients during laparoscopic donor nephrectomy. Patients were treated with 02 supplementation by face mask, fluid restriction and diuretic. All the patients were relieved of symptoms with radiological improvement. The possible causes of this unusual complication following laparoscopic surgery appear to be prolonged lateral decubitus position and high intraoperative fluid infusion.

Keywords: Laparoscopic donor nephrectomy, Unilateral pulmonary edema


How to cite this article:
Modi M, Shah V, Modi P. Unilateral Dependant Pulmonary Edema During Laparoscopic Donor Nephrectomy: Report of Three Cases. Indian J Anaesth 2009;53:475-7

How to cite this URL:
Modi M, Shah V, Modi P. Unilateral Dependant Pulmonary Edema During Laparoscopic Donor Nephrectomy: Report of Three Cases. Indian J Anaesth [serial online] 2009 [cited 2019 Nov 12];53:475-7. Available from: http://www.ijaweb.org/text.asp?2009/53/4/475/60320


   Introduction Top


Lap aroscopic live donor nephrectomy is currently an established method of kidney procurement at many institutions worldwide. This offers less post-operative pain, shorter hospital stay and early post operative con­valescenceto the donor. [1],[2],[3]

Despite these advantages, laparoscopic donor nephrectomy may be associated with arrhythmias, pneu­mothorax and pneumomediastinum. [4],[5] Recently, unilat­eral pulmonary edema is described for the first time during laparoscopic donor nephrectomy. [6] We report three cases ofunilateral dependant pulmonary edema during laparoscopic donornephrectomy. Patients were treated with 02 supplementation, fluid restriction and diuretics. We report this complicationpossibly second­atyto overhydration and prolonged lateral decubitus position in laparoscopic donor nephrectomy:


   Case 1 Top


A healthy 40-year-old 60kg man with ASA-I was posted for laparoscopic donor nephrectomy. He was given balanced general anaesthesia. Induction was with thiopental sodium and suxamethonium was given to fa­cilitate endotracheal intubation. Nitrous oxide, isoflurane and vecumnium were used formaintenance anaesthe­sia. Continuous monitoringwith ECC; Sp02, EtCO2, NIBP, airway pressure and urine output, temperature was performed. Patient was given lateraldecubitus posi­tion for surgery and totaltime in this position was 5 1/2 hours.The patient was hydrated with 7.5 L of fluids which included 7Lof lactated Ringer's solution and 500 ml of gelofusine. 30g of 20% mannitol was given for osmotic diuresis before renal arterial dissection and again 15 minutes prior to clamping of the renal artery. The total intraoperative urine output was 2L.

After kidney procurement, patient's saturation fell from 100% to 94%. On examination of chest, fine crepitations in dependant lungwere audible. The air­way pressure was increased to 5 mm Hg from the baseline. Intravenous furosemide was given in dose of 40 mg and fluid administration was stopped. X-ray chest revealed unilateral edema of the dependant lung [Figure 1]. The Sp02 improved to 98% and an additional urine output of 1500m1 obtained over 3 hours after diuretic. Patient was extubated after clinical and radiological improvement.


   Case 2 Top


A 55-year-old 65 kg man with ASA-I was donor. Patient positioning and anaesthesia and monitoring were similar to those in case I. The total time in the right lateral decubitus was 6 hours. There was drop in 02 saturation from 100% to 93% gradually and increase in airway pressure at incision closure time. The patient was hy­drated with 8L of fluid of balanced lactated Ringer's so­lution and Gelofusine.Mannitol was given while renal ar­terial dissection and 15 minutes prior to renal artery clamp. Total urine output was 3150 ml. During ausculta­tion of chest, he had fine crepitations on dependant lung. X-ray chest was performed and diagnosis of unilateral pulmonary edema was confirmed. Patient was treated with 02 with face mask, head up position, fluid restric­tion and diuretics; extubationwas performed in recov­ery room. In recovery room, urine output was 2415 miHe was recovered on Ptpostoperative day.


   Case 3 Top


A58-year-old 45kg female, having history of hy­pertension was on single regular antihypertensive. She was subjected for laparoscopic donor nephrectomy. Patient positioning and anaesthesia were similarin to those in case-1 and 2.The total time in the lateral decu­bitus was 5 hours. She had drop in oxygen saturation at the time of kidney procurement. Total fluid was 5L which included lactated Ringer's solution and 500m1 of Gelofusine. Mannitol was given. Urine output was 2450mL She had crepitation on dependant lung and 02 saturation remained between 94%-95% tillthe comple­tion of surgery. She was extubated and shifted to recovery room. Treatment similarto case -1,2 were given in recovery room urine output was 3225 ml. She was also recovered in tint postoperative day with clear chest and clear chest radiograph.


   Discussion Top


Prolonged pneumoperitoneum and high intraabdominal pressure cause decreased renal blood flow, oliguria and renal dysfunction in the recipient as first demonstrated in a porcine model by London and colleagues . [7] The most probable explanation is that in addition to direct compression of the renal arteries by the pneumoperitoneum, the pressure exerted on the inferiorvena cava results in partial compression that in­creases venous resistance, thereby decreasing preload and stroke volume. To alleviate these effects, vigorous intravenous hydration is recommended in an attempt to optimize preload and promote diuresis. In a porcine model, Demyttenaere et al have shown thatthe decrease in stroke volume and renal cortical p erfus ion could b e prevented by simple hydration of 15ml.kgl.h -1 saline combined with a bolus 20 ml.kg -1 saline. [8]

In addition, lateral decubitus position contributes to hernodynamic alterations by decreasing preload throughthe effect of gravity on venous return. Yokoyarna et al found no significant change inhemodynamic values afterposturalchange of theirpatientsfromsupinetolat­eral but a significant reduction in stroke volume after postural change to kidney position; these patients re­ceived a fluid regime of20 ml.kg -1 .h -1 of ciystalloids. [9]

In accordance with the literature, we have hy­drated all donors with 15 ml.kg -1 .hour -1 .Though most of our donors had no detrimental effect of aggressive fluid regime, three developed unilateral pulmonary edema. The possible explanation fordevelopment of unilateral pulmonary edema is overzealous hydration of the donor in lateraldecubitus position. The lateral decubitus position alters the physiology of pulmonary ventilation& perfusion. The dependant zones of the lung become hyperperfused& hypoventilated where as the non dependant portion become hypoperfused & hyperventilated. This results in V%Q mismatch. In ad­dition, under anaesthesia FRC of both lungs decreased which causes the non dependant lungto be more com­pliant while the dependant lung becomes less compli­ant. Further, the decreased compliance of the depen­dant lung is exaggerated by restriction of thoracic ex­pansion due to upward displacement of the descen­dant hemidiaphmm, mediastinal and abdominal com­pression& patient position maneuver including flexion of the operation table& elevation of the kidney rest. In the lateral position, the increased gravitation of the per­fusion of the dependant lung results in increased pul­monary capillary pressure with consequent increase of fluid transudation. This results in propensity forunilat­eral pulmonary edema in the dependant lung [10],[11]

Prolonged surgery was the only riskfactor found in all three cases.Morrisroe et al have recently shown unilateral pulmonary edema after laparoscopic donor nephrectomy in two cases. [6] The combination of pa­tient factors, intraoperative hydration mandatory to ensure optimal kidney function during laparoscopic pro­curement, and prolonged decubitus positioning together were thought to be the cause of dependant lung edema.

Routinely, we are not monitoring central venous pressure because central venous pressure monitoring will not help much in lateral position [12],[13] Preoperative hydration may improve renalhemodynamic as well as decrease the intraoperative fluid requirements. In apro­spective randomized dose-finding study Martens Zur Borg etal have suggested that overnight infusion and a bolus of colloid just before pneumoperitoneum attenu­ate hemodynamic compromise from pneumoperito­neum. [14] Though we have not practiced, such strategy may decrease intraoperative fluid requirement.

In conclusion, overzealous hydration during laparoscopic donornephrectomy requiring more than 5 hours time may lead to pulmonary edema of the de­pendant lung. Loop diuretics and restriction of fluid in­fusion is required to treat such condition.



 
   References Top

1.Ratner LB. Kavoussi LR, Sroka Iv1, et al. Laparoscopic assisted live donor nephrectomy-a comparison with the open approach. Transplantation 1997; 63:229-233.  Back to cited text no. 1      
2.Jacobs S, Cho E, Dunkin B, et al. Laparoscopic live do­nor nephrectomyahe University of Maryland 3-year experience. JUrol 2000;164:1 494.  Back to cited text no. 2      
3.Buell JF, Lee L, Martin JE, et al. Laparoscopic donor nephrectomy v s. Open live donor nephrectomy: a qual­ity of life and functional study. Clin Transplant 2005; 19:102-9.  Back to cited text no. 3      
4.Jhao LC, Han JS, Loeb S, et al. Thoracic complications of urologic laparoscopy: correlation between radio­graphic findings and clinical manifestations. J Endourol 200822: 607-14.  Back to cited text no. 4      
5.Abreu SC, Sharp DS,RamaniAP, etal. Thoracic compli­cations during urologic laparoscopy. J Uro12004;171: 1451-5.  Back to cited text no. 5      
6.Morrisroe SN, Wall RT Lu AD. Unilateral pulmonary edema after laparoscopic donor nephrectomy: report of two cases. Journal ofEndourology 2007;2 1:760-2.  Back to cited text no. 6      
7.London ET, Ho HS, Neuhaus AMC, et al. Effects of intravascular volume expansion on renal function dur­ing prolonged CO2 pneumoperiteum. Ann Surg 2000; 231:195-201.  Back to cited text no. 7      
8.Demyttenaere S\ Feldman LS, Bergman S, et al. Does aggressive hydration reverse the effects of pneumo­peritoneum on renal perfusion? Surg Endosc 2006;20:274-280.  Back to cited text no. 8      
9.Yokoyama Ivi Ueda W, Hirakawa M. Hemodynamic ef­fects of the lateral decubitus position and the kidney rest lateral decubitus position during anaesthesia. Br J Anaesth 2000;84:753-757.  Back to cited text no. 9      
10.ABaraka, RMoghrabi, AYazigi, et al. Umlateral pulmo­nary edema/atelectaisis in the lateral decubitus posi­tion.Anaesthesia 1987; 42:171-174.  Back to cited text no. 10      
11.Snoy FJ, Woodside JR. Unilateral pulmonary edema (down syndrome) following urological operation J Urol 1984;132:776-777.  Back to cited text no. 11      
12.K Fujise, K Shingu, S Matsumoto, ANagata, O Mikami and T Matsuda,et al. The effects of lateral position on cardiopulmonary function during laparoscopic urologi­cal surgery. AnesthAnalg 1998; 87:925-930.  Back to cited text no. 12      
13.Potger KC, Elliott D. Reproducibility of central venous pressures in supine and lateral position. a pilot evalua­tion of the phlebo static axis in critically ill patients. Heart­Lung 1991;23:285-99.  Back to cited text no. 13      
14.Mertens zurBorg 1R, Di Biase M, Uerbrugge S, etal. Com­parison of three perioperative fluid regimes for laparoscopic donor nephrectomy: Aprospective random - izeddose-findingstudy. SurgEndosc2008;22:146-150.  Back to cited text no. 14      


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  In this article
    Abstract
    Introduction
    Case 1
    Case 2
    Case 3
    Discussion
    References
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