A 69-yr-old, 50 kg woman with pelvic pain is admitted for laparoscopic carbon dioxide laser lysis of pelvic adhesions. Her history for hypertension and hyperlipidemia is significant. Her clinical exam is unremarkable, and although there are no cardiac symptoms, her preoperative electrocardiogram (ECG) shows a left anterior fascicular block. Her medication includes hydrochlorothiazide, triamterene, and gemfibrozil. She is not allergic to any medication. She is sedated with midazolam 2mg IV and taken to the operating room. Thereafter, monitors are placed, and she has a successful induction of general endotracheal anesthesia. She is maintained with desflurane/fentanyl/oxygen/air mixture. Pancuronium is used for muscle relaxation. During the operation, the patient receives a total of 2,100 ml of crystalloid fluid IV over the 185-min procedure. (1,000ml lactate Ringer’s solution before the procedure started, 1,000ml 0.9% saline during the first 90min, and 100ml 0.9% saline during the final 95min). The surgeon infuses a lactated Ringer’s solution through the laparoscope to wash away blood and debris and thereby improve visualization. The nurse tells you that a total amount of 4,400 ml was instilled, and a similar amount was recovered by the surgeon while sucking out the peritoneal cavity. Her urinary output is 300 ml. At the end of the surgery, the neuromuscular blockade is reversed with glycopyrrolate and neostigmine. Spontaneous breathing ensues. The patient responds to verbal command and maintains a 10-s head lift. The endotracheal tube is removed, but, while still in the operating room, she becomes less alert and seems to have difficulty breathing. You give her 100% oxygen via mask and the saturation improves to 93% from 84%. Your nerve stimulator shows four strong twitches. Pupils are small to midsize, but you elect to give naloxone IV up to 0.4 mg. As expected, there is no clinical improvement. You examine the patient’s chest and bilateral rales are heard over the lower half of her lung fields. You take her to the postoperative recovery ward and a chest x-ray confirms the diagnosis of pulmonary edema. How will you treat this? What investigations will you do? Why is the patient in pulmonary edema?
KeywordsPeritoneal Cavity Pulmonary Edema Neuromuscular Blockade Spontaneous Breathing Verbal Command
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