Postoperative negative pressure pulmonary edema following repetitive laryngospasm even after reversal of neuromuscular blockade by sugammadex: a case report

Severe pulmonary edema occurred during endobronchial ultrasound under monitored anesthesia care - A case report

BACKGROUND

Endobronchial ultrasound (EBUS) is widely used to diagnose lung cancer. Monitored anesthesia care (MAC) can enhance patient comfort and procedural conditions during EBUS. EBUS under MAC is usually safe but can lead to various complications.

CASE

A 34-year-old male who had increased sputum for two months showed an enlarged paratracheal lymph node and planned for lymph node biopsy by EBUS. During EBUS under MAC, an unexpected oxygen saturation decline required intervention. After intubation, copious frothy fluid was suctioned from the bronchi, and oxygenation was recovered. A narrowed trachea and the EBUS bronchoscope might have resulted in upper airway obstruction, and suction performed under these conditions might have caused pulmonary edema. The patient received non-invasive ventilation and high-flow nasal cannula and recovered without complications.

CONCLUSIONS

When there is an expected risk of upper airway obstruction during EBUS, careful preoperative evaluation and preparation are essential to prevent negative pressure pulmonary edema.

A Complex Presentation of Acute Postoperative Negative-Pressure Pulmonary Edema: A Case Report and Review of Literature

Negative-pressure pulmonary edema (NPPE) is an uncommon diagnosis that requires a high clinical suspicion to recognize and manage and has high morbidity and mortality. It usually results secondary to markedly negative intrapleural pressure due to the forceful inspiration against the obstructed airway from upper airway infection, tumor, or laryngospasm. We present a case of a 27-year-old female with morbid obesity who underwent sleeve gastrectomy and developed NPPE upon emergence from anesthesia. The focus of supportive care should be on addressing the obstruction in the upper airway through either endotracheal intubation or cricothyroidotomy. Additionally, it is important to initiate lung-protective positive-pressure ventilation and promote diuresis, unless the patient is in a state of shock. The resolution of pulmonary edema is typically swift, partially due to the preservation of alveolar fluid clearance mechanisms. In the literature review, we delve into the clinical presentation, pathophysiology, and management of NPPE or post-obstructive pulmonary edema.

Adverse events of sugammadex that occurred in a Korean population

Background

With increasing use, the incidence of adverse events associated with sugammadex, a neuromuscular blockade reverser, is increasing. This study aimed to identify and analyze cases of adverse events caused by sugammadex reported in Korean population.

Methods

Out of a total of 12 cases detected using various keywords in the Korean Journal of Anesthesia, Anesthesia and Pain Medicine (Seoul), KoreaMed, PubMed, EMBASE, Web of Science, and The Cochrane Library-CENTRAL from 2013 to December 2020, 10 cases directly associated with sugammadex were selected.

Results

Adverse events included five cases of anaphylaxis, one case of cardiac arrest, one case of profound bradycardia, one case of negative pressure pulmonary edema, and two cases of incomplete recovery. Three patients had American Society of Anesthesiologists physical status ≥ 3, two had emergency surgery, and two had a history of allergic reaction. Neuromuscular monitoring was applied in nine cases. The average dose of sugammadex was 2.87 mg/kg, and there were six cases in which one full vial was used, regardless of the state of neuromuscular recovery. Sugammadex was administered immediately after surgery in two cases, at train of four (TOF) 0 in four cases, at TOF 3 in one case, and after evaluation of the clinical signs only with no neuromuscular monitoring in one case.

Conclusions

Even with neuromuscular monitoring, an excessive dose of sugammadex was observed. Given that adverse events tend to occur within 10 min of administration, continuous monitoring is important even after administration.

A rare case of type II negative pressure pulmonary edema following extraction of inhaled peanuts in a 21-month-old boy

To date, only one case of pediatric type II negative pressure pulmonary edema (NPPE) caused by removal of an endobronchial foreign body has been documented. We report another case of type II NPPE that developed after extraction of inhaled peanuts. A 21-month-old boy who presented with wheezing and intermittent cough for 1 month after eating peanuts was admitted to our department. A chest computed tomographic scan showed foreign bodies lodged in the right main bronchus. Fiberoptic bronchoscopy was performed, and three pieces of peanuts were removed. Fifteen minutes after this procedure, the child grew restless and started coughing with frothy pink sputum. Tachypnea and rales were observed. A chest radiograph showed patchy opacification in both lungs, especially in the right lower zone, leading to the diagnosis of type II NPPE. Intravenous furosemide and dexamethasone were immediately administered, followed by non-invasive continuous positive airway pressure ventilation. Twelve hours later, the patient recovered uneventfully and was discharged home the following day. In conclusion, pediatric type II NPPE rapidly occurs following the relief of upper airway obstruction. Clinicians need to be aware of the acuteness and manifestations of type II NPPE to make an early diagnosis and initiate prompt treatment.

Extracorporeal membrane oxygenation for the anesthetic management of a patient with severe airway stenosis caused by thyroid carcinoma invasion

The treatment of a thyroid carcinoma extending into the thoracic cavity with severe airway stenosis is difficult, since there is a risk of acute respiratory decompensation at every stage of anesthesia. Extracorporeal membrane oxygenation (ECMO) is a life support technique for maintaining both the cardiac and respiratory functions. It is used for the management of acute, severe, reversible respiratory or cardiac failure refractory to conventional management. We herein describe the use of ECMO for the anesthetic management of an elderly patient with severe airway stenosis caused by thyroid carcinoma invasion, which underwent total thyroidectomy with the resection of four tracheal rings and end-to-end anastomosis under a median sternotomy. Although the risks and benefits should be carefully weighed before a decision to use ECMO is made, the use of ECMO in the management of general anesthesia may be a rational and effective strategy for maintaining oxygenation.

Advantages and pitfalls of clinical application of sugammadex

Sugammadex, a modified γ-cyclodextrin, is one of the drugs focused on in the anesthetic field because it provides rapid and complete reversal from neuromuscular blockade (NMB) by encapsulating rocuronium. Its introduction has revolutionized anesthesia practice because it is a safe, predictable, and reliable neuromuscular antagonist. Hence, its use has increased worldwide. Further, it has been in the spotlight for recovering from deep NMB in laparoscopic surgery and improving the surgical condition. Recently, studies have been conducted on the postoperative outcome after deep NMB and use of sugammadex in various clinical conditions. However, with increase in sugammadex use, reports regarding its complications are increasing. Appropriate dosing of sugammadex with quantitative neuromuscular monitoring is emphasized because under-dosing or over-dosing of sugammadex might be associated with unexperienced complications. Sugammadex is now leaping into an ideal reversal agent, changing the anesthesia practice.

Paroxysmal Laryngospasm: A Rare Condition That Respiratory Physicians Must Distinguish from Other Diseases with a Chief Complaint of Dyspnea

Background

In recent years, we have observed respiratory difficulty manifested as paroxysmal laryngospasm in a few outpatients, most of whom were first encountered in a respiratory clinic. We therefore explored how to identify and address paroxysmal laryngospasm from the perspective of respiratory physicians.

Methods

The symptoms, characteristics, auxiliary examination results, treatment, and prognosis of 12 patients with paroxysmal laryngospasm treated in our hospital from June 2017 to October 2019 were analyzed.

Results

Five males (42%) and 7 females (58%) were among the 12 Han patients sampled. The average age of the patients was 49.25 ± 13.02 years. The disease course ranged from 14 days to 8 years and was characterized by sudden dyspnea, an inability to inhale and exhale, a sense of asphyxia, and voice loss during an attack. Eight patients with gastroesophageal reflux were cured after antacid treatment. One case of upper respiratory tract infection (URI) was completely relieved after symptomatic treatment. One patient with left vocal cord paralysis experienced complete relief after specialist treatment by an otorhinolaryngologist. Episodes in 1 patient were significantly reduced after lifestyle improvement. One patient experienced spontaneous relief after rejecting treatment.

Conclusions

Paroxysmal laryngospasm is a rare laryngeal disease that generally occurs secondary to gastroesophageal reflux disease (GERD), and antireflux therapy is frequently effective for its treatment. A respiratory physician should master and identify the symptoms and differentiate this condition from hysterical stridor, reflux-related laryngospasm, and asthma. Timely referral to otolaryngologists, gastroenterologists, and other specialists for standardized examination and regular treatment should be provided when necessary.

Risk of bronchospasm and coronary arteriospasm with sugammadex use: a post marketing analysis

Introduction:

Sugammadex is used for the reversal of neuromuscular blockade caused by rocuronium bromide and vecuronium bromide. As part of the post licensing phase of drug development, adverse events related to the use of sugammadex are still being uncovered and being reported. The potential association between sugammadex and adverse events bronchospasm and coronary arteriospasm using a retrospective pharmacovigilance signal analysis was carried out.

Methods:

Food and Drug Administration’s Adverse Event Reporting System database was used to run disproportionality analyses to investigate the potential association of sugammadex with bronchospasm or coronary arteriospasm. In this analysis we report the adverse event signal using frequentist methods of Relative reporting ratio (RRR), proportional reporting ratio (PRR), reporting odds ratio (ROR) and the Bayesian based Information Component metric.

Results:

A statistically significant disproportionality signal is found between sugammadex and bronchospasm (n = 44; chi-squared = 2993.87; PRR = 71.95 [95% CI: 54.00–95.85]) and sugammadex and coronary arteriospasm (n = 6; chi-squared = 209.39; PRR = 43.82 [95% CI: 19.73–97.33]) as per Evans criteria. Both statistically significant disproportionality signals persisted when stratified by gender. Based upon dynamic cumulative PRR graph, the PRR value has steadily increased and the 95% CI narrowed since December 2012.

Conclusion:

The results of the pharmacovigilance analysis highlight a statistically significant disproportionality signal between sugammadex usage and bronchospasm and coronary arteriospasm adverse events. Physicians need to be aware of these adverse events when using sugammadex. The results of the pharmacovigilance signal analysis highlight a statistically significant disproportionality signal between sugammadex usage and bronchospasm and coronary arteriospasm adverse events. Physicians need to be aware of these adverse events when using sugammadex.

Negative pressure pulmonary edema: a case report

Background

The negative pressure pulmonary edema is rare clinical situation which caused mainly by upper airway obstruction. However except upper airway obstruction, there may be other pathophysiological disorders making patients more vulnerable to pulmonary edema. Based on these disorders, upper airway obstruction is the trigger to induce negative pressure pulmonary edema.

Case presentation

This case was a 5-year-old girl with tumor on saddle area, her hormones level were abnormal preoperatively, such as cortisol, adrenocorticotrophic hormone, free T4 and total T4. During the stage of induction, negative pressure pulmonary edema took place due to mild upper airway obstruction. And the instant chest Computer tomography proved diagnosis clue. After intensive care, most lung field of this girl recovered to normal within 48 h.

Conclusion

The patient with abnormal hormone levels is vulnerable to pulmonary edema, mild upper airway obstruction triggered negative pressure pulmonary. Thus pre-operation hormones supplement is as important as keeping upper airway unobstructed.

Negative pressure pulmonary edema after general anesthesia: A case report and literature review

RATIONALE

Negative pressure pulmonary edema (NPPE) is a dangerous clinical complication and potentially life-threatening emergency without prompt diagnosis and intervention during recovery period after anesthetic extubation.

PATIENT CONCERNS

A 25-year-old woman has undergone endoscopic thyroidectomy. After extubation, the patient developed acute respiratory distress with high airway resistance accompanied with wheezing, oxyhemoglobin saturation (SpO2) decreased to 70%. With positive pressure mask ventilation, her condition was stable, SpO2 99%. However, the patient developed pink frothy sputum with diffuse bilateral rales 30 min later after transported to surgical intensive care unit (SICU).

DIAGNOSES

Negative pressure pulmonary edema.

INTERVENTIONS

The patient was undergone assisted ventilation with continuous positive airway pressure (CPAP) and furosemide 20 mg was given intravenously.

OUTCOMES

Postoperative day (POD) 2 her condition became stable, computed tomography (CT) scan indicated the pulmonary edema disappeared. The patient was discharged 6 days later. No abnormalities were observed during following 4 weeks.

LESSONS

Although usually the onset of NPPE is rapid, with individual differences NPPE is still challenging. Increased vigilance in monitoring, diagnosis, and treatment are essential to prevent aggravation and further complication.

Diffuse alveolar hemorrhage following sugammadex and remifentanil administration: A case report

RATIONALE

Diffuse alveolar hemorrhage (DAH) is a rare life-threatening condition that accompanies general anesthesia. Negative-pressure pulmonary edema (NPPE) is a rare cause of DAH.

PATIENT CONCERNS

A 25-year-old male patient developed hemoptysis following remifentanil administration by bolus injection with sugammadex at the emergence from general anesthesia.

DIAGNOSIS

Chest x-ray and computed tomography showed DAH.

INTERVENTIONS

Conservative care was provided with 4L of oxygen via nasal prong, 20 mg of Lasix and 2500 mg of tranexamic acid.

OUTCOMES

The patient was discharged uneventfully.

LESSONS

Muscle rigidity by remifentanil and the dissociated reversal of neuromuscular blockade by sugammadex was suspected as the cause of NPPE-related DAH. Therefore, the possibility NPPE-related DAH should be considered when using a bolus of remifentanil and sugammadex during emergence from general anesthesia.

Acute Postobstructive Pulmonary Edema Following Laryngospasm in Elderly Patients: A Case Report

Only a few cases regarding postobstructive pulmonary edema following laryngospasm in older patients aged more than 60 years have been reported; however, acute pulmonary edema or pulmonary hemorrhage would be more deadly to elderly patients who have cerebrovascular disease than young healthy adults. After review of the literature, we report an unusual case of a 67-year-old man with ischemic cerebrovascular disease, who underwent carotid angioplasty and stenting and experienced severe pulmonary edema and hemorrhage secondary to laryngospasm after general anesthesia with laryngeal mask airway. The patient required positive-pressure ventilation, supportive treatment, and active cerebroprotection in the intensive care setting for 3 days before the edema resolved, and subsequently made a complete recovery without new onset of neurologic sequelae. The possible pathophysiological mechanisms, precaution, and preventative strategy of postobstructive pulmonary edema in older patients are discussed.