CORRESPONDENCE
Acute Subdural Hematoma Causing Neurogenic Pulmonary Edema Following Lumbar Spine Surgery To JNA Readers: A 43-year-old male weighing 65 kg, diagnosed with L5-S1 intradural extramedullary tumor (? neurofibroma) was posted for L5-S1 laminectomy and tumor excision. Routine preoperative examination and investigations were within normal limits. Balanced general anesthesia was used with fentanyl, propofol, rocuronium, desflurane, and nitrous oxide. A total of 3 mcg/kg of fentanyl was used over 3 hours. A total of 2.5 L of crystalloids were administered, blood loss was 350 mL, and urine output 600 mL. Surgery was uneventful except for a momentary gush of cerebrospinal fluid (CSF) on dural opening. Following reversal, respiratory rate was 12 to 14/minute with tidal volume of 450 to 500 mL, but there was no eye opening on command. After 15 minutes of observation, trachea was extubated as train of four ratio (TOF ratio assessed using TOF Watch-SX, manufactured by Organon, Dublin, Ireland) was >1, cough reflex was good, chest was clear, and SpO2 was 100%. Thirty minutes later, respiration suddenly became shallow with SpO2 85% on supplemental O2 via face mask. The pulse was 120/minute and blood pressure was 80/56 mm Hg with bilateral crepitations in the chest. Pink frothy secretions appeared in the endotracheal tube following intubation and chest x-ray showed diffuse infiltrates. A diagnosis of pulmonary edema was made. He was placed on positive pressure ventilation. Dopamine infusion, frusemide 80 mg, and morphine 6 mg The authors have no funding or conflicts of interest to disclose.
J Neurosurg Anesthesiol
FIGURE 1. Axial slice of gradient echo sequence of magnetic resonance imaging brain done postoperatively, showing thin right sided frontoparietal subdural hematoma
were administered. A 12-lead ECG, transthoracic echocardiography, Nterminal of the prohormone brain natriuretic peptide (NT-ProBNP) level, and pulmonary computed tomography angiography were done. They were unremarkable except for a raised NT-ProBNP (1670 pg/mL). He gradually improved overnight and was extubated the following day, conscious, with stable vitals, normal blood gases, and clear chest. His only complaint was of a persistent frontal headache. A noncontrast magnetic resonance imaging of the brain was therefore done 2 days later, which revealed a thin right frontoparietal subdural hematoma (SDH) (Fig. 1). He was treated conservatively and discharged on the seventh postoperative day. Four days later, he was readmitted with a CSF leak from the operative site which had gone undiagnosed previously. He thereafter underwent CSF leak repair under general anesthesia uneventfully. Formation of postoperative pulmonary edema can occur after a variety of inciting events. Fluid over-
Volume 00, Number 00, ’’ 2015
load or cardiogenic edema was unlikely in this case. No airway obstruction occurred postoperatively which could have led to negative pressure pulmonary edema. Moreover, the patient did not rapidly improve with the institution of positive pressure ventilation.1 Echocardiography and pulmonary computed tomography angiography done postoperatively were normal, thereby ruling out pulmonary embolism. Retrospective analysis after admission for CSF leak pointed toward neurogenic pulmonary edema (NPE) as a likely diagnosis. A sudden reduction in intracranial pressure due to CSF release, when the dura was opened intraoperatively, could have led to the caudal shift of the brain and traction on arachnoid mater and dural veins, leading to formation of acute SDH.2 Catecholamine surge following SDH could have precipitated NPE. The delayed presentation with slow recovery within 24 to 48 hours also favored NPE.3 Literature showing corelation between NPE and NT-ProBNP levels is sparse. Although acute SDH after www.jnsa.com |
1
Copyright r 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Correspondence
spine surgery has been described in literature, the additional complication of NPE precipitated by this has not been reported.
Abhijeet Raha, MD, PDF Ashoo Wadehra, MD
2 | www.jnsa.com
J Neurosurg Anesthesiol
Kavita Sandhu, MD Arnab Dasgupta, MD, PDF Department of Neuroanaesthesiology and Critical Care, Max Superspeciality Hospital, Saket, New Delhi, India
REFERENCES 1. Bhaskar B, Fraser JF. Negative pressure pulmonary edema revisited: pathophysio-
Copyright
r
Volume 00, Number 00, ’’ 2015
logy and review of management. Saudi J Anaesth. 2011;5:308–313. 2. Reina MA, Lo´pez A, Benito-Leo´n J, et al. Cerebral and spinal subdural hematoma: a rare complication of epidural and subarachnoid anesthesia. Rev Esp Anestesiol Reanim. 2004;51:28–39. 3. Davison DL, Terek M, Chawla SL. Neurogenic pulmonary edema. Crit Care. 2012; 16:212.
2015 Wolters Kluwer Health, Inc. All rights reserved.
Copyright r 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Acute Subdural Hematoma Causing Neurogenic Pulmonary Edema Following Lumbar Spine Surgery To JNA Readers: A 43-year-old male weighing 65 kg, diagnosed with L5-S1 intradural extramedullary tumor (? neurofibroma) was posted for L5-S1 laminectomy and tumor excision. Routine preoperative examination and investigations were within normal limits. Balanced general anesthesia was used with fentanyl, propofol, rocuronium, desflurane, and nitrous oxide. A total of 3 mcg/kg of fentanyl was used over 3 hours. A total of 2.5 L of crystalloids were administered, blood loss was 350 mL, and urine output 600 mL. Surgery was uneventful except for a momentary gush of cerebrospinal fluid (CSF) on dural opening. Following reversal, respiratory rate was 12 to 14/minute with tidal volume of 450 to 500 mL, but there was no eye opening on command. After 15 minutes of observation, trachea was extubated as train of four ratio (TOF ratio assessed using TOF Watch-SX, manufactured by Organon, Dublin, Ireland) was >1, cough reflex was good, chest was clear, and SpO2 was 100%. Thirty minutes later, respiration suddenly became shallow with SpO2 85% on supplemental O2 via face mask. The pulse was 120/minute and blood pressure was 80/56 mm Hg with bilateral crepitations in the chest. Pink frothy secretions appeared in the endotracheal tube following intubation and chest x-ray showed diffuse infiltrates. A diagnosis of pulmonary edema was made. He was placed on positive pressure ventilation. Dopamine infusion, frusemide 80 mg, and morphine 6 mg The authors have no funding or conflicts of interest to disclose.
J Neurosurg Anesthesiol
FIGURE 1. Axial slice of gradient echo sequence of magnetic resonance imaging brain done postoperatively, showing thin right sided frontoparietal subdural hematoma
were administered. A 12-lead ECG, transthoracic echocardiography, Nterminal of the prohormone brain natriuretic peptide (NT-ProBNP) level, and pulmonary computed tomography angiography were done. They were unremarkable except for a raised NT-ProBNP (1670 pg/mL). He gradually improved overnight and was extubated the following day, conscious, with stable vitals, normal blood gases, and clear chest. His only complaint was of a persistent frontal headache. A noncontrast magnetic resonance imaging of the brain was therefore done 2 days later, which revealed a thin right frontoparietal subdural hematoma (SDH) (Fig. 1). He was treated conservatively and discharged on the seventh postoperative day. Four days later, he was readmitted with a CSF leak from the operative site which had gone undiagnosed previously. He thereafter underwent CSF leak repair under general anesthesia uneventfully. Formation of postoperative pulmonary edema can occur after a variety of inciting events. Fluid over-
Volume 00, Number 00, ’’ 2015
load or cardiogenic edema was unlikely in this case. No airway obstruction occurred postoperatively which could have led to negative pressure pulmonary edema. Moreover, the patient did not rapidly improve with the institution of positive pressure ventilation.1 Echocardiography and pulmonary computed tomography angiography done postoperatively were normal, thereby ruling out pulmonary embolism. Retrospective analysis after admission for CSF leak pointed toward neurogenic pulmonary edema (NPE) as a likely diagnosis. A sudden reduction in intracranial pressure due to CSF release, when the dura was opened intraoperatively, could have led to the caudal shift of the brain and traction on arachnoid mater and dural veins, leading to formation of acute SDH.2 Catecholamine surge following SDH could have precipitated NPE. The delayed presentation with slow recovery within 24 to 48 hours also favored NPE.3 Literature showing corelation between NPE and NT-ProBNP levels is sparse. Although acute SDH after www.jnsa.com |
1
Copyright r 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Correspondence
spine surgery has been described in literature, the additional complication of NPE precipitated by this has not been reported.
Abhijeet Raha, MD, PDF Ashoo Wadehra, MD
2 | www.jnsa.com
J Neurosurg Anesthesiol
Kavita Sandhu, MD Arnab Dasgupta, MD, PDF Department of Neuroanaesthesiology and Critical Care, Max Superspeciality Hospital, Saket, New Delhi, India
REFERENCES 1. Bhaskar B, Fraser JF. Negative pressure pulmonary edema revisited: pathophysio-
Copyright
r
Volume 00, Number 00, ’’ 2015
logy and review of management. Saudi J Anaesth. 2011;5:308–313. 2. Reina MA, Lo´pez A, Benito-Leo´n J, et al. Cerebral and spinal subdural hematoma: a rare complication of epidural and subarachnoid anesthesia. Rev Esp Anestesiol Reanim. 2004;51:28–39. 3. Davison DL, Terek M, Chawla SL. Neurogenic pulmonary edema. Crit Care. 2012; 16:212.
2015 Wolters Kluwer Health, Inc. All rights reserved.
Copyright r 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
