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Bland Pulmonary Hemorrhage After Sevoflurane Exposure
October 2013, Vol 144, No. 4_MeetingAbstracts
Signs and Symptoms of Chest Diseases | October 2013
Bland Pulmonary Hemorrhage After Sevoflurane Exposure Rebecca Liu, MD; David Hsia, MD Los Angeles, CA Chest. 2013;144(4_MeetingAbstracts):906A. doi:10.1378/chest.1703660
Abstract SESSION TITLE: Miscellaneous Case Report Posters II SESSION TYPE: Affiliate Case Report Poster PRESENTED ON: Tuesday, October 29, 2013 at 01:30 PM - 02:30 PM INTRODUCTION: Bland diffuse alveolar hemorrhage (DAH) may result from various medical conditions or secondary to drugs and toxins. Of the drugs associated with DAH, inhaled anesthetics have not been reported as a cause. Here we describe a case of bland DAH after elective surgery with sevoflurane. CASE PRESENTATION: A 31-year-old male underwent elective excision of a perirectal pilonidal cyst. Medical history was only significant for marijuana use. Preoperative evaluation and laboratory values were normal and the intraoperative course was uncomplicated. During surgery, he received midazolam 4 mg intravenous (IV), fentanyl 200 mcg IV, and 2 hours of inhaled sevoflurane via endotracheal intubation. Forty-five minutes after extubation, he developed hypoxemia and hemoptysis. Arterial blood gas showed pH of 7.42, PCO2 of 40, and PaO2 of 52 with 85% saturation on room air. Chest x-ray (CXR) revealed bilateral patchy infiltrates and computerized tomography (CT) demonstrated diffuse ground glass opacities without evidence of pulmonary embolism (Figure 1). Hypoxemia persisted despite aggressive pulmonary toilet, diuretics and empiric treatment for pneumonia. Serum hemoglobin dropped by 3 g/dL compared to preoperative values without bleeding at the surgical site. Pulmonary function testing was notable for DLCO 150% of predicted. Bronchoscopy confirmed DAH on bronchoalveolar lavage (Figure 2) and cultures were negative. Echocardiography was normal. Serologic testing was negative for HIV, vasculitis, connective tissue disease, or hepatitis. The patient was treated with methylprednisolone 1 gram IV daily for 3 days. His symptoms and CXR returned to normal by post-operative day 5. DISCUSSION: Our patient had DAH without clinical, serologic, or pathologic evidence of systemic disease. Given the immediate post-operative onset and limited medication exposure, we suspect the most likely causative agent is inhaled sevoflurane. DAH has not been previously reported with sevoflurane, midazolam, or fentanyl. However, fentanyl and midazolam were used during bronchoscopy without detrimental effect on clinical improvement. One other report describes post-operative DAH in a patient with end-stage renal disease and daily crack cocaine abuse undergoing cataract surgery. Anesthetic agents used were sevoflurane, propofol, and midazolam; however, DAH was attributed to dysfunctional platelets and cocaine abuse. CONCLUSIONS: Sevofluorane may be a rare cause of DAH. Reference #1: Ioachimescu OC and Stoller JK. Diffuse aveolar hemorrhage: Diagnosing it and finding the cause. Cleveland Clinic Journal of Medicine. April 2008; 75(4): 258-280. Reference #2: Khanna AK, and Cummings KC. J Anaesthesiol Clin Pharmacol. 2012 Oct-Dec; 28(4):520523. Reference #3: www.pneumotox.com DISCLOSURE: The following authors have nothing to disclose: Rebecca Liu, David Hsia
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Signs and Symptoms of Chest Diseases | October 2013
Bland Pulmonary Hemorrhage After Sevoflurane Exposure Rebecca Liu, MD; David Hsia, MD Los Angeles, CA Chest. 2013;144(4_MeetingAbstracts):906A. doi:10.1378/chest.1703660
Abstract SESSION TITLE: Miscellaneous Case Report Posters II SESSION TYPE: Affiliate Case Report Poster PRESENTED ON: Tuesday, October 29, 2013 at 01:30 PM - 02:30 PM INTRODUCTION: Bland diffuse alveolar hemorrhage (DAH) may result from various medical conditions or secondary to drugs and toxins. Of the drugs associated with DAH, inhaled anesthetics have not been reported as a cause. Here we describe a case of bland DAH after elective surgery with sevoflurane. CASE PRESENTATION: A 31-year-old male underwent elective excision of a perirectal pilonidal cyst. Medical history was only significant for marijuana use. Preoperative evaluation and laboratory values were normal and the intraoperative course was uncomplicated. During surgery, he received midazolam 4 mg intravenous (IV), fentanyl 200 mcg IV, and 2 hours of inhaled sevoflurane via endotracheal intubation. Forty-five minutes after extubation, he developed hypoxemia and hemoptysis. Arterial blood gas showed pH of 7.42, PCO2 of 40, and PaO2 of 52 with 85% saturation on room air. Chest x-ray (CXR) revealed bilateral patchy infiltrates and computerized tomography (CT) demonstrated diffuse ground glass opacities without evidence of pulmonary embolism (Figure 1). Hypoxemia persisted despite aggressive pulmonary toilet, diuretics and empiric treatment for pneumonia. Serum hemoglobin dropped by 3 g/dL compared to preoperative values without bleeding at the surgical site. Pulmonary function testing was notable for DLCO 150% of predicted. Bronchoscopy confirmed DAH on bronchoalveolar lavage (Figure 2) and cultures were negative. Echocardiography was normal. Serologic testing was negative for HIV, vasculitis, connective tissue disease, or hepatitis. The patient was treated with methylprednisolone 1 gram IV daily for 3 days. His symptoms and CXR returned to normal by post-operative day 5. DISCUSSION: Our patient had DAH without clinical, serologic, or pathologic evidence of systemic disease. Given the immediate post-operative onset and limited medication exposure, we suspect the most likely causative agent is inhaled sevoflurane. DAH has not been previously reported with sevoflurane, midazolam, or fentanyl. However, fentanyl and midazolam were used during bronchoscopy without detrimental effect on clinical improvement. One other report describes post-operative DAH in a patient with end-stage renal disease and daily crack cocaine abuse undergoing cataract surgery. Anesthetic agents used were sevoflurane, propofol, and midazolam; however, DAH was attributed to dysfunctional platelets and cocaine abuse. CONCLUSIONS: Sevofluorane may be a rare cause of DAH. Reference #1: Ioachimescu OC and Stoller JK. Diffuse aveolar hemorrhage: Diagnosing it and finding the cause. Cleveland Clinic Journal of Medicine. April 2008; 75(4): 258-280. Reference #2: Khanna AK, and Cummings KC. J Anaesthesiol Clin Pharmacol. 2012 Oct-Dec; 28(4):520523. Reference #3: www.pneumotox.com DISCLOSURE: The following authors have nothing to disclose: Rebecca Liu, David Hsia
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