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Massive hemoptysis during general endotracheal anesthesia in adults with Cystic Fibrosis
Journal of Clinical Anesthesia 42 (2017) 17–18
Contents lists available at ScienceDirect
Journal of Clinical Anesthesia
Correspondence Massive hemoptysis during general endotracheal anesthesia in adults with Cystic Fibrosis
Keywords: Adult Cystic Fibrosis Massive hemoptysis Airway management
Cystic Fibrosis (CF) is a multisystem autosomal recessive disease that affects nearly 30,000 people in the United States [1]. Improved medical management has increased the average life expectancy in CF patients to 45.2 years [2]. Anesthesiologists are increasingly faced with managing the adverse sequelae of this disease in adult CF patients undergoing surgery. We report two cases of massive hemoptysis in adult CF patients under general endotracheal anesthesia, one resulting in death. A 22 year old, 53 kg female with mild pulmonary dysfunction (FEV1.0 90% of predicted) underwent an endoscopic retrograde cholangiopancreatography under general anesthesia. Induction and endotracheal tube (ETT) placement were uneventful, and anesthesia was maintained with sevoflurane in oxygen and air mixture and muscle relaxant. The patient was mechanically ventilated on volume control with application of 5 cm H2O positive end expiratory pressure. Low tidal volumes were used to keep peak inspiratory pressure (PIP) and plateau pressure (Pplat) b 30 cm H2O. As airway reflexes returned during emergence, copious amounts of bright red blood were noted in the ETT. Oxygen saturation (SpO2) fell precipitously and pulmonary compliance deteriorated. Bronchoalveolar lavage with ice cold saline and epinephrine was performed multiple times with a flexible bronchoscope until bleeding subsided. She was extubated on postoperative day 1 and discharged home 2 days later. A 31 year old, 55 kg female with significant pulmonary dysfunction (FEV1.0 31% of predicted), liver cirrhosis, and diabetes mellitus was scheduled for sinus surgery. Induction, maintenance, and ventilator management were as described for the first case, and PIP and Pplat remained b 30 cm H2O throughout the surgery. The case proceeded uneventfully until emergence when the patient started coughing up bright red blood into the ETT. Manual ventilation was difficult and ETCO2 could not be measured. The patient became hypoxic, bradycardic, and hypotensive and was treated with atropine and epinephrine. Flexible bronchoscopy with lavage was performed repeatedly until the bleeding subsided, but pulmonary compliance did not improve. Resuscitative efforts continued until the patient could be safely transferred to the intensive care unit where she was placed on high frequency oscillatory ventilation. Her postoperative course was complicated by persistent
1
This author contributed to the manuscript preparation.
http://dx.doi.org/10.1016/j.jclinane.2017.08.007 0952-8180/© 2017 Elsevier Inc. All rights reserved.
respiratory failure, anoxic encephalopathy, and renal failure. She expired on POD 6. Adult CF patients with massive hemoptysis have a poor prognosis with adverse effects on overall lung function and higher risk of recurrence and death [3]. Although most patients have advanced lung disease, 22% of CF patients with massive hemoptysis have only mild pulmonary dysfunction [3]. While major hemoptysis has been associated with a high mortality rate in CF patients, there have been few reports describing this complication during anesthesia [4,5]. Factors associated with positive pressure ventilation, including prolonged increases in airway wall tension [4] and the effects of shear stress may be precipitating influences. Optimal approaches to invasive mechanical ventilator management in CF are not known, and utilizing protective lung strategies in our patients did not prevent this complication from occurring, nor were they effective postoperatively in our second patient. Hemoptysis started in both of our patients during emergence. Although maybe coincidental, it is plausible that hypertension associated with coughing against the endotracheal tube might initiate bleeding in dilated and weakened bronchial vessels or abnormal pulmonary arterioles. Employing strategies to prevent coughing during emergence should be considered in CF patients. There are no evidence based guidelines on how to identify CF patients at risk for intraoperative hemoptysis. This, coupled with the absence of evidence-based recommendations for invasive ventilation in severely decompensated CF patients can complicate assessment of morbidity and mortality risks from hemoptysis during anesthesia. Conflict of interest None. Financial disclosures None. References [1] Cystic Fibrosis Foundation. About cystic fibrosis. https://www.cff.org/What-is-CF/ About-Cystic-Fibrosis/, Accessed date: 25 May 2017. [2] 2015 U.S. Cystic Fibrosis Foundation Annual Data Report to the Center Directors; 2016. [3] Flume PA, Yankaskas JR, Ebeling M, Hulsey T, Clark LL. Massive hemoptysis in cystic fibrosis. Chest 2005;128:729–38. [4] McDougall RJ, Sherrington CA. Fatal pulmonary haemorrhage during anaesthesia for bronchial artery embolization in cystic fibrosis. Paediatr Anaesth 1999;9(4):345–8. [5] Wiehe M. Massive hemoptysis during monitored anesthesia care for esophagogastroduodenoscopy with percutaneous endoscopic gastrostomy tube placement: a case report. AANA J Feb 2010;78(1):43–6.
Judith Aronsohn MD Hofstra Northwell School of Medicine, Long Island Jewish Medical Center, Department of Anesthesiology, 270-05 76th Ave., New Hyde Park, NY 11040, United States E-mail address: [email protected]
18
Correspondence
Oonagh Dowling PhD Hofstra Northwell School of Medicine, Long Island Jewish Medical Center, Department of Anesthesiology, 270-05 76th Ave., New Hyde Park, NY 11040, United States E-mail address: [email protected] Michelle Kars MD Hofstra Northwell School of Medicine, Long Island Jewish Medical Center, Department of Anesthesiology, 270-05 76th Ave., New Hyde Park, NY 11040, United States
E-mail address: [email protected] Adam Roseman MD Hofstra Northwell School of Medicine, Long Island Jewish Medical Center, Department of Anesthesiology, 270-05 76th Ave., New Hyde Park, NY 11040, United States E-mail address: [email protected] 15 July 2017 Available online xxxx
Contents lists available at ScienceDirect
Journal of Clinical Anesthesia
Correspondence Massive hemoptysis during general endotracheal anesthesia in adults with Cystic Fibrosis
Keywords: Adult Cystic Fibrosis Massive hemoptysis Airway management
Cystic Fibrosis (CF) is a multisystem autosomal recessive disease that affects nearly 30,000 people in the United States [1]. Improved medical management has increased the average life expectancy in CF patients to 45.2 years [2]. Anesthesiologists are increasingly faced with managing the adverse sequelae of this disease in adult CF patients undergoing surgery. We report two cases of massive hemoptysis in adult CF patients under general endotracheal anesthesia, one resulting in death. A 22 year old, 53 kg female with mild pulmonary dysfunction (FEV1.0 90% of predicted) underwent an endoscopic retrograde cholangiopancreatography under general anesthesia. Induction and endotracheal tube (ETT) placement were uneventful, and anesthesia was maintained with sevoflurane in oxygen and air mixture and muscle relaxant. The patient was mechanically ventilated on volume control with application of 5 cm H2O positive end expiratory pressure. Low tidal volumes were used to keep peak inspiratory pressure (PIP) and plateau pressure (Pplat) b 30 cm H2O. As airway reflexes returned during emergence, copious amounts of bright red blood were noted in the ETT. Oxygen saturation (SpO2) fell precipitously and pulmonary compliance deteriorated. Bronchoalveolar lavage with ice cold saline and epinephrine was performed multiple times with a flexible bronchoscope until bleeding subsided. She was extubated on postoperative day 1 and discharged home 2 days later. A 31 year old, 55 kg female with significant pulmonary dysfunction (FEV1.0 31% of predicted), liver cirrhosis, and diabetes mellitus was scheduled for sinus surgery. Induction, maintenance, and ventilator management were as described for the first case, and PIP and Pplat remained b 30 cm H2O throughout the surgery. The case proceeded uneventfully until emergence when the patient started coughing up bright red blood into the ETT. Manual ventilation was difficult and ETCO2 could not be measured. The patient became hypoxic, bradycardic, and hypotensive and was treated with atropine and epinephrine. Flexible bronchoscopy with lavage was performed repeatedly until the bleeding subsided, but pulmonary compliance did not improve. Resuscitative efforts continued until the patient could be safely transferred to the intensive care unit where she was placed on high frequency oscillatory ventilation. Her postoperative course was complicated by persistent
1
This author contributed to the manuscript preparation.
http://dx.doi.org/10.1016/j.jclinane.2017.08.007 0952-8180/© 2017 Elsevier Inc. All rights reserved.
respiratory failure, anoxic encephalopathy, and renal failure. She expired on POD 6. Adult CF patients with massive hemoptysis have a poor prognosis with adverse effects on overall lung function and higher risk of recurrence and death [3]. Although most patients have advanced lung disease, 22% of CF patients with massive hemoptysis have only mild pulmonary dysfunction [3]. While major hemoptysis has been associated with a high mortality rate in CF patients, there have been few reports describing this complication during anesthesia [4,5]. Factors associated with positive pressure ventilation, including prolonged increases in airway wall tension [4] and the effects of shear stress may be precipitating influences. Optimal approaches to invasive mechanical ventilator management in CF are not known, and utilizing protective lung strategies in our patients did not prevent this complication from occurring, nor were they effective postoperatively in our second patient. Hemoptysis started in both of our patients during emergence. Although maybe coincidental, it is plausible that hypertension associated with coughing against the endotracheal tube might initiate bleeding in dilated and weakened bronchial vessels or abnormal pulmonary arterioles. Employing strategies to prevent coughing during emergence should be considered in CF patients. There are no evidence based guidelines on how to identify CF patients at risk for intraoperative hemoptysis. This, coupled with the absence of evidence-based recommendations for invasive ventilation in severely decompensated CF patients can complicate assessment of morbidity and mortality risks from hemoptysis during anesthesia. Conflict of interest None. Financial disclosures None. References [1] Cystic Fibrosis Foundation. About cystic fibrosis. https://www.cff.org/What-is-CF/ About-Cystic-Fibrosis/, Accessed date: 25 May 2017. [2] 2015 U.S. Cystic Fibrosis Foundation Annual Data Report to the Center Directors; 2016. [3] Flume PA, Yankaskas JR, Ebeling M, Hulsey T, Clark LL. Massive hemoptysis in cystic fibrosis. Chest 2005;128:729–38. [4] McDougall RJ, Sherrington CA. Fatal pulmonary haemorrhage during anaesthesia for bronchial artery embolization in cystic fibrosis. Paediatr Anaesth 1999;9(4):345–8. [5] Wiehe M. Massive hemoptysis during monitored anesthesia care for esophagogastroduodenoscopy with percutaneous endoscopic gastrostomy tube placement: a case report. AANA J Feb 2010;78(1):43–6.
Judith Aronsohn MD Hofstra Northwell School of Medicine, Long Island Jewish Medical Center, Department of Anesthesiology, 270-05 76th Ave., New Hyde Park, NY 11040, United States E-mail address: [email protected]
18
Correspondence
Oonagh Dowling PhD Hofstra Northwell School of Medicine, Long Island Jewish Medical Center, Department of Anesthesiology, 270-05 76th Ave., New Hyde Park, NY 11040, United States E-mail address: [email protected] Michelle Kars MD Hofstra Northwell School of Medicine, Long Island Jewish Medical Center, Department of Anesthesiology, 270-05 76th Ave., New Hyde Park, NY 11040, United States
E-mail address: [email protected] Adam Roseman MD Hofstra Northwell School of Medicine, Long Island Jewish Medical Center, Department of Anesthesiology, 270-05 76th Ave., New Hyde Park, NY 11040, United States E-mail address: [email protected] 15 July 2017 Available online xxxx