Bilateral upper lobe pulmonary edema occurred during laparoscopy

Abstract

Abstract A 25 year-old woman was diagnosed with ruptured ectopic pregnancy. During laparoscopic surgery, the patient was in Trendelenberg position (20° degrees). Massive froth in the endotracheal tube was observed at the end of surgery. A portable chest x-ray, checked at the end of the operation, showed diffuse haziness in both upper lung fields. After one hour of aggressive treatment with drugs and positive mechanical ventilation, the amount of froth in the endotracheal tube reduced considerably. Considering the symptom and radiologic findings, we concluded that diffuse bilateral upper lung field haziness was due to atypical pulmonary edema. We supposed that the rapid improvement of pulmonary edema was due to redistribution of fluid to the lowest part of lung by immediate reversing the patient`s Trendelenberg position and aggressive treatment. Key Words: Laparoscopic surgery, Trendelenberg position, Upper lobe pulmonary edema.

Case A 25 year-old woman weighing 56 kg and with a height of 154 cm, diagnosed with ruptured ectopic pregnancy, revealed a hemoglobin level of 7.4 g/dl with a hematocrit of 21.5% at admission. Patient`s chest x-rays were normal. We induced anesthesia with ketamine and rocuronium. Maintenance of anesthesia was done with N2O-O2-sevoflurane. CO2 insufflation was done and patient was tilted to 20° Trendelenberg position. After intravenous infusion of 3 units of packed red blood cells (PRBC), 1,250 ml of crystalloid, and 500 ml of colloid solution over a period of 50 minutes, at a FiO2 of 0.5, arterial blood gas analysis (ABGA) showed a pH of 7.31, PaCO2 of 39.3 mmHg, PaO2 of 37.3 mmHg, base excess of -6.5, hemoglobin level of 8.7 g/dl, and hematocrit 25%. After completion of operation, delivery of anesthetics was stopped and 100% oxygen was given, then reversal of muscle relaxation was done. Before extubation, patient showed spasmodic coughing and pink frothy sputum with extrusion of large amounts of foamy fluid. Immediately, a chest x-ray was taken and diffuse haziness was seen over both upper lung fields (Fig. 1). A 15° head up position was immediately done and aggressive treatment with continuous positive pressure ventilation combined with furosemide was done. About 1 hour later, 1,250 ml of urine was excreted and ABGA showed a pH of 7.27, PaCO2 of 44 mmHg, PaO2 of 379 mmHg, base excess of -6.8 at a FiO2 of 1.0. After recovery of mental state, tracheal reflexes and respiratory functions, patient was able to reach tidal volume of greater than 8 ml/kg and extubated. In the recovery room, patient was maintained in a head up position. ABGA showed PaO2 of 147.6 mmHg, hemoblogin level of 15.2 g/dl at 35% venturi mask oxygen. Haziness seen previously in both upper lung fields disappeared in the first postoperative chest x-ray (Fig. 2).