Negative Pressure Pulmonary Oedema: A Rare Case Report of Two Brothers

Abstract

A 19-year-old-man, an Iranian, a professional athlete, (weight, 65 kg; height, 170cm), a candidate for varicocele surgery under general anaesthesia. He was without any history of previous anaesthetic exposure, illness, use of drug and history of allergy. Chest X-ray, ECG, laboratory tests and physical examination were within normal limits. The patient was accepted for anaesthesia, as he had ASA I physical status.In the operation room, after placing standard monitors, the patient was premedicated with injection fentanyl 100 μgm intravenous and general anaesthesia was induced with Thiopental Sodium 5 mg/ kg, Atracurium 0.5 mg/ kg . He was intubated without problems using a 7.5 mm oral endotracheal tube that was fixed 22 cm from the mouth. Over the operative period (1 h), 1000 mL of lactated Ringer's solution was given. Anaesthesia was maintained by Halotan 0.8%, N 2o: O 2 (50 : 50) and Atracurium. The tracheal intubation, anaesthesia, mechanical ventilation, and surgical procedure were uneventful. At the end, oropharyngeal suctioning was done and reversed using injection Neostigmine 2.5 mg IV, and injection Atropine Sulfate 1.0mg IV and subsequently, the trachea was extubated. Directly after extubation, the patient developed laryngospasm and became agitated. Respiratory distress, tachypnoea and cyanosis were observed. Spontaneous ventilation with 100% oxygen could not be assisted by bag and mask ventilation sufficiently and he developed laryngospasm with severe respiratory distress. Subsequently, arterial oxygen saturation decreased to a low 70. The patient was reintubated after administration of Succinylcholine (1mg.kg) and Dexamethasone 8mg. Suctioning of the tube revealed copious amounts of pink, frothy sputum. Chest radiograph showed a small right lower lobe infiltrate. In operation room, he was placed on mechanical ventilation and treated with positive end-expiratory pressure (PEEP) of 10 cm H 2 O, high fractional inspiratory oxygen concentration (FIO 2 ), intravenous furosemide and morphin initially. Arterial blood gas levels were within normal limits. His extubation was successfully carried out 4 hours after his initial reintubation. He had an uneventful recovery and was transferred to the surgical ward.In surgical ward, remarkable note was derangement in coagulation profile, prothrombin time (PT) and partial thromboplastin time (PTT) (PT=24sec, PTT=54sec). The patient recovered completely and was discharged home on the postoperative day. Case TWOOur second case, brother of the case one, underwent general anaesthesia for septoplasty 3 years later in our hospital. A 17 yearold-man, an Iranian,and a professional athlete, (weight, 82 kg; height, 187 cm). He was also without history of previous anaesthetic exposure, illness, drug use and history of allergy. Chest X-ray ,ECG, laboratory tests and physical examination were within normal limits. The patient was accepted for anaesthesia, as he had ASA I physical status. In the operation room, after placing standard monitors, the patient was premedicated with inject...