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| LETTER TO EDITOR |
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| Year : 2021 | Volume
: 41
| Issue : 1 | Page : 49-50 |
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Pulmonary edema after robot-assisted radical prostatectomy
Lei-Ying Huang1, Zhi-Fu Wu2, Guang-Huan Sun3, Hou-Chuan Lai1
1 Department of Anesthesiology, Tri-Service General Hospital and National Defense Medical Center, Taipei, Taiwan
2 Department of Anesthesiology, Tri-Service General Hospital and National Defense Medical Center, Taipei; Department of Anesthesiology, Chi Mei Medical Center, Tainan City, Taiwan
3 Department of Surgery, Division of Urology, Tri-Service General Hospital and National Defense Medical Center, Taipei, Taiwan
| Date of Submission | 05-Feb-2020 |
| Date of Decision | 12-Feb-2020 |
| Date of Acceptance | 27-Feb-2020 |
| Date of Web Publication | 05-Apr-2020 |
Correspondence Address:
Dr. Hou-Chuan Lai
#325, Section 2, Chenggung Road, Neihu 114, Taipei
Taiwan
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/jmedsci.jmedsci_22_20
How to cite this article:
Huang LY, Wu ZF, Sun GH, Lai HC. Pulmonary edema after robot-assisted radical prostatectomy. J Med Sci 2021;41:49-50 |
Dear Editor,
Pulmonary edema (PE) can be a life-threatening emergency perioperatively. Anesthesiologists must understand the clinical factors and related risks of PE. PE development following robot-assisted radical prostatectomy (RARP) is very rare.[1] Here, we reported a case of PE after elective RARP.
A 72-year-old, 65 kg, 172 cm man with Type 2 diabetes underwent RARP for prostate cancer. His physical examinations, vital signs, and preoperative laboratory values were all within normal limits, which included a normal chest X-ray (CXR). During surgery, intra-abdominal pressure (IAP) was maintained at 12–15 mmHg in the 30° Trendelenburg with lithotomy position. The duration of pneumoperitoneum was 315 min, and the total anesthetic time was 407 min. His hemodynamics were stable during surgery. The total administered fluid intake was 1700 mL, with an estimated blood loss of approximately 100 mL, along with 200 mL perioperative urine output. At the end of the surgery, his endotracheal tube was extubated after confirming muscle relaxant reversal. In the postanesthesia care unit (PACU), his oxygen saturation (SpO2) was 92%–96% with supplemental oxygen at 3 L/min by nasal cannula, and his respiratory rate was 25–30 breaths/min. In the PACU, he showed no edema of the neck, head, upper airway, or frothy sputum while coughing. He complained of moderate pain in the PACU, which was relieved by intravenous administration of 50 μg fentanyl. One hour later, he was sent to the general ward with stable hemodynamics, but his respiratory rate was still 25–30 breaths/min. A few hours after arrival to the general ward, he was clearly conscious but showed dyspnea and SpO2 <85% despite the use of an oxygen mask with 60% oxygen. During his time in the general ward, total fluid intake/output was 500/200 mL. An emergency CXR was obtained and showed PE [Figure 1]a, and arterial blood gas analysis gave pH 7.37, PaO2 56.1 mmHg, and PaCO2 53.9 mmHg. Foamy sputum was noted after he was reintubated, and therefore, ventilatory support was given. Intravenous furosemide 80 mg was administered, and his urine output reached >1000 mL in a few hours. The CXR showed obviously decreased edema on postoperative day 1 [Figure 1]b, and his lungs were clear to auscultation bilaterally. He was then extubated and subsequently discharged on postoperative day 8 without any sequelae. | Figure 1: (a) Postoperative chest radiograph showed pulmonary edema, (b) chest radiograph showed obviously decreased edema on postoperative day 1
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Pneumoperitoneum is a crucial element in laparoscopic surgery, and standard-pressure pneumoperitoneum (SPP) is achieved by insufflating the abdominal cavity with CO2 to maintain an IAP of 12–16 mmHg. However, SPP may cause various clinical problems such as cardiac, pulmonary, intestinal, renal, and testicular damage, as well as PE.[2],[3] Moreover, the Trendelenburg positioning may exacerbate these problems during RARP. 1] To the best of our knowledge, Hong et al.[1] were the first to report that a case of PE found in the PACU was attributed to prolonged (4 h) pneumoperitoneum with a concomitantly high IAP at 15–20 mmHg during RARP. Therefore, previous studies have recommended that a reduced IAP (5–10 mmHg) be used in laparoscopic surgery to prevent these complications, especially in patients with limited cardiac, pulmonary, or renal function. Abdominal wall lifting combined with low-pressure pneumoperitoneum may be another viable alternative.[1],[3],[4]
In our case, the PE after RARP was not caused by preexisting heart disease, arrhythmias, anesthetic overdose, negative airway pressure, or fluid overload. Therefore, we postulate the prolonged SPP with an IAP of 12–15 mmHg and the steep Trendelenburg position as the etiology. Prolonged SPP in the Trendelenburg position may cause PE by increasing pulmonary arterial pressure and decreasing pulmonary compliance.[1],[5],[6] In this situation, early detection of PE using lung ultrasonography with effective treatment in the PACU is recommended.[7] In addition, if PE is suspected after extubation in RARP cases, intensive hemodynamic monitoring is warranted. Postoperative ICU care and early reintubation should also be considered.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.
Acknowledgment
We would like to thank the patient for signing the informed consent for publication.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | |  |
| 1. | Hong JY, Oh YJ, Rha KH, Park WS, Kim YS, Kil HK. Pulmonary edema after da Vinci-assisted laparoscopic radical prostatectomy: A case report. J Clin Anesth 2010;22:370-2.  |
| 2. | Sharma KC, Kabinoff G, Ducheine Y, Tierney J, Brandstetter RD. Laparoscopic surgery and its potential for medical complications. Heart Lung 1997;26:52-64. |
| 3. | Zhang X, Wei J, Song X, Zhang Y, Qian W, Sheng L, et al. Comparison of the impact of prolonged low-pressure and standard-pressure pneumoperitoneum on myocardial injury after robot-assisted surgery in the Trendelenburg position: Study protocol for a randomized controlled trial. Trials 2016;17:488. |
| 4. | Neudecker J, Sauerland S, Neugebauer E, Bergamaschi R, Bonjer HJ, Cuschieri A, et al. The European Association for Endoscopic Surgery clinical practice guideline on the pneumoperitoneum for laparoscopic surgery. Surg Endosc 2002;16:1121-43. |
| 5. | Binetti A, Mosing M, Sacks M, Duchateau L, Gasthuys F, Schauvliege S. Impact of Trendelenburg (head down) and reverse Trendelenburg (head up) position on respiratory and cardiovascular function in anaesthetized horses. Vet Anaesth Analg 2018;45:760-71. |
| 6. | Newman MM, Kligerman M, Willcox M. Pulmonary hypertension, pulmonary edema, and decreased pulmonary compliance produced by increased ICP in cats. J Neurosurg 1984;60:1207-13. |
| 7. | Mayo PH, Copetti R, Feller-Kopman D, Mathis G, Maury E, Mongodi S, et al. Thoracic ultrasonography: A narrative review. Intensive Care Med 2019;45:1200-11. |
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