Without treatment ovarian tumours may enlarge to massive proportions. Spohn' reported the removal of a tumour weighing nearly 150 kg (328 lb). This was the largest which was recorded amongst papers studied in a review of the literature by the authors-appropriately this was in Texas. This report concerns a case of respiratory arrest precipitated by an enormous ovarian cyst. Case reportA 57-year-old woman, with a huge abdominal swelling, was admitted in extreme respiratory distress to the casualty department. There was gross pitting oedema of the whole body and engorged veins in the neck and over the anterior abdominal wall. A provisional diagnosis of massive ovarian cyst was made with cardiac failure secondary to compression of the lungs, mediastinum and inferior vena cava.Immediately after arrival the patient sustained respiratory arrest and she was intubated with an 8.0 mm cuffed 'Portex' endotracheal tube. Intermittent positive pressure ventilation with 100% oxygen was followed by a rapid return of spontaneous respiratory activity. Pancuronium 6 mg was given intravenously and ventilation was continued using a Manley Pulmovent delivering 50% nitrous oxide in oxygen. A minute volume of 6 litreslmin, with a tidal volume of 450 ml, was achieved at an inflation pressure of 70 cm of water. Figure 1 shows the appearance of the patient shortly after intubation.A Teflon catheter was introduced percutaneously via the right external jugular vein into the right atrium and when attached to a central venous pressure manometer a value of 40 cm of water was measured from the sternal angle. The pulse rate was 100 per minute and the blood pressure was 110/60 mmHg.A paracentesis catheter was passed into the swelling and drainage of fluid was started at a maximum rate of 1 litre/h. After 3 litres had been removed the ventilator inflation pressure fell to 35 cmH20. The patient was transferred to the intensive care unit where intermittent positive pressure ventilation was continued employing a Cape ventilator with F102 of 0.35, tidal volume of 700 ml and a frequency of 12/ min. Arterial blood gas analysis showed pH 7.42, Po; 88 mmHg, Pco2 38 mmHg, HCOJ 28 mol/l and base excess + 3*5mmol/l.The cardiac failure was treated with diuretics and the central venous pressure fell to 5 cmH20 after 48 h.After 4 days a total of 44 litres of fluid had been drained from the abdomen, the catheter was then removed and the patient was extubated the following day. However on the sixth day accumulation of fluid began once more and tracheal intubation and ventilation were again necessary.
Anaesthetists are familiar with the Riley concept' of lung function which imagines that functioning alveoli all have the same ratio of ventilation to perfusion, and that a proportion of the blood flowing through the lungs takes no part in gas exchange whatever. During the breathing of 100% oxygen this blood shunting is attributed to anatomical pathways and perfusion of non-ventilated alveoli, while during air breathing, alveolar abnormalities of the ratio of ventilation to perfusion, in addition to shunting, constitute the venous admixture occurring through the lungs. The size of the shunt or venous admixture as a percentage of the total flow can be calculated by using the Shunt Equation.In an awake, normal man, at rest, that proportion of the cardiac output which in the Riley idiom takes no part in gas exchange amounts to a mean of 6.4Z3 when breathing air, while in the anaesthetised subject this venous admixture increases to 9-21 %." When ventilation is controlled, when the patient's position is altered and when disturbances of the chest mechanics by thoracotomy take place, further changes in the size of the lung shunt occur. The presence of pulmonary arteriovenous fistulae inevitably gives rise to an additional proportion of the cardiac output which does not take part in gas exchange, and the opportunity has been taken, when a patient suffering from such a condition presented for thoracotomy, to study the changes in venous admixture at various stages during the procedure.Preoperative data A male patient, aged 27 years, and weighing 62 kg, presented in hospital after repeated haemoptyses. He was known to have pulmonary arterio-venous fistulae and at the age of 16 had undergone a left upper lobe resection for this disease. He had also suffered from nose bleeds in the past but gave no history suggesting the presence of fistulae elsewhere or the occurrence of paradoxical emboli passing through the lungs. There was no family history of a similar condition.On physical examination the patient was seen to have marked central cyanosis and clubbing of fingers and toes. There were no thrills or murmurs over the chest, no other abnormalities, and particularly no evidence of generalised telangiectasia of the mucous membranes.Investigations showed : haemoglobin 20.3 g/dl and PCV 54.4%; the platelet count was 247 x lo9/] and coagulation studies were normal. Pulmonary function studies showed a FVC 4.75 litre, FEV, 4.1 litre and PEFR of 585 I/min and the ECG was normal. Right heart catheterisation and pulmonary angiography revealed the presence of multiple pulmonary arterio-venous fistulae, most numerous in the right lung and especially in the right middle lobe, while the SurgeryA right thoracotomy was undertaken to ligate some of the most accessible fistulae near the surface of the right lung in the expectation that the shunt would be reduced and the hazard of bleeding diminished.Two large fistulae, one in the middle lobe and one in the posterior segment of the upper lobe were dissected out along with the related vessels an...
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