Failed sevoflurane induction of anesthesia in a child affected by congenital cystic adenomatoid malformation of the lungs.

A case of congenital lung cyst disease is presented here. The inhalational induction of anesthesia with sevoflurane failed to ensure satisfactory intubation condition. Then, intravenous ketamine and rocuronium were given and they facilitated the intubation.

INTRODUCTION

This report presents an interesting case of congenital lung cyst disease, anesthetized by sevoflurane inhalation[1] and it demonstrated unsuitable condition for intubation. This may reflect defective physiological transfer of inhalational agents. The situation was remedied by supplement of ketamine and rocuronium for intubation and then the inhalation was continued with sevoflurane.

CASE REPORT

The case presented here is a 27-week gravid premature girl, weighing 1000 g at birth, delivered by a G7 P6+1 mother who had eclampsia at 27 weeks of gestation.

At the age of 4 weeks, the girl was intubated and ventilated for 26 days due to respiratory impairment. Later, she was diagnosed as a case of (1) retinopathy of prematurity and (2) congenital bronchopulmonary dysplasia.

No other medical disease was documented. She was referred from the peripheral hospital to the ophthalmic unit at King Fahad Medical City for laser surgery to control congenital retinopathy.

The girl was admitted to the NICU, and investigated and found to have right lung cysts. The treating physician suggested an anesthesia consultation for laser surgery.

The girl was kept in an incubator. On examination, she was breathing spontaneously, was active and on oxygen supplements given at a rate of 2 l.m-1 via mask. Auscultation of the chest did not elicit any abnormality, but normal breathing sounds and no added sounds. Vital signs were as follows. Heart rate: 170 b.m-1; blood pressure: 85/40 mmHg; RR: 35 b.m-1. She was on oral feeding.

Laboratory investigations showed the following results: urea 1.4 mmol/l; creatinine 19.0 μmol/l; K 5.5 meq/l; Na 141 meq/l; Hb 11 g/dl;0 platelets: 497×10.e9/l; coagulation profile: prothrombin time (PT): 12.4; activated partial thromboplastin time (APTT): 40.1.

The pulmonologist who monitored the chest condition advised that the lung cysts were small in size. A pediatric surgical consultation for management of the lung cysts was obtained. It was suggested that there was no need for urgent surgery, but if pneumothorax develops during laser surgery then immediate intervention should take place.

On 18 August 2007, anesthesia was given. Inhalational induction was done using sevoflurane. The anesthesiologist took long for induction before laryngoscopy and tried intubation but found that her condition was not fit for intubation as she was “fighting.” So, since she was on sevoflurane inhalation supplemental ketamine was given intravenously at a dose of 0.5 mg/kg. Atropine 0.1 mg was given as well and then recuronium 1 mg.kg-1 was injected, so laryngoscopy was done and trachea was intubated successfully. The respiration resumed as pressure support ventilation mood with the tube in place.

Anesthesia was maintained on sevoflurane 2% in air:oxygen mixture. Respiration at the conclusion of procedure was spontaneous with occasional ventilatory manual support. Finally, at the 1-hour procedure, the girl was extubated after she recovered completely and was sent back to NICU on 4 l O2 with SpO2 100%. Later on, she was discharged to the primary hospital on 28 August 2007 in a good condition.

DISCUSSION

Congenital cystic adenomatoid malformation (CCAM) was reviewed recently.[1] It is a rare congenital malformation of the lung representing 25% of congenital lung malformations and 95% of congenital lung lesions.[23] This lesion occurs more often in males (male:female=1.8:1), and is primarily unilateral, but may occur bilaterally.[4]

CCAM with severe respiratory dysfunction from birth was reported and the anesthetic course was dependent on sevoflurane inhalation and spontaneous respiration. In a Japanese report 5-day-old-boy with CCAM underwent removal of a large cyst which was present at lower lobe of right lung. Anesthesia was induced slowly and maintained with oxygen and sevoflurane. Severe airway obstruction occurred transiently by the secretion from the lung cyst. Thereafter, the surgery was completed safely and his postoperative course was uneventful.[5]

A recent report describes a left pneumonectomy performed on a 6-week-old female infant suffering from respiratory distress related to cystic changes affecting the entire left lung. Anesthesia was induced with sevoflurane in oxygen and spontaneous ventilation was maintained until intubation of the right main bronchus was secured. The postoperative course was uneventful. The pathological diagnosis was pulmonary interstitial emphysema.[67] In the case we have presented here, inhalation of sevoflurane was given for a long period; the patient did not relax enough for intubation though high concentration (6%) of sevoflurane was given and 3 minutes had passed. Ketamine supplement and recuronium were used to secure the airway. We conclude that induction of these cases for surgery are adopting inhalational method to prevent cysts from distention if IPPV is used. But the lung pathology may elongate the inhalational induction for manipulation of the airway. Alternatively, intravenous induction with anesthetics and muscle relaxant would control the airway. Also, gentile ventilation would provide oxygenation and elimination of carbone dioxide.