|LETTER TO EDITOR
|Year : 2021 | Volume
| Issue : 2 | Page : 180-182
Anesthetic management of a case of post tubercular unilateral total lung fibrosis undergoing laparoscopic cholecystectomy
Amiya Kumar Barik1, Ashutosh Kaushal1, Ajit Kumar2, Jaharan Mohanta2
1 Department of Anaesthesiology, Critical Care and Pain, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India
2 Department of Anaesthesiology, Critical Care and Pain, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
|Date of Submission||07-Sep-2020|
|Date of Decision||23-Mar-2021|
|Date of Acceptance||23-Mar-2021|
|Date of Web Publication||18-May-2021|
Dr. Ajit Kumar
Department of Anaesthesiology, Critical Care and Pain, All India Institute of Medical Sciences, Rishikesh - 249 203, Uttarakhand
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Barik AK, Kaushal A, Kumar A, Mohanta J. Anesthetic management of a case of post tubercular unilateral total lung fibrosis undergoing laparoscopic cholecystectomy. Int J Health Allied Sci 2021;10:180-2
|How to cite this URL:|
Barik AK, Kaushal A, Kumar A, Mohanta J. Anesthetic management of a case of post tubercular unilateral total lung fibrosis undergoing laparoscopic cholecystectomy. Int J Health Allied Sci [serial online] 2021 [cited 2022 Sep 30];10:180-2. Available from: https://www.ijhas.in/text.asp?2021/10/2/180/316284
Pulmonary tuberculosis is prevalent in developing country like India. Posttubercular complications can range from minor abnormality to substantial derangements in lung function. Lung fibrosis is one of such complications, characterized by excess collagen deposition in the lung parenchyma which leads to stiffening of the lung and impaired gaseous exchange. Laparoscopic surgery is becoming popular day by day because of better cosmetics, less pain, early ambulation, and lesser hospital stay. However, it is associated with disadvantages like the creation of pneumoperitoneum and reverse Trendelenburg position leading to compromised cardiopulmonary functions.
A 40-year-old female with chronic calculus cholecystitis was posted for laparoscopic cholecystectomy under general anesthesia. She had a history of left-sided pleural effusion following pulmonary tuberculosis 25 years back (completed 12 months course of anti-tubercular treatment). Respiratory examination revealed grossly diminished air entry on the left side chest with rhonchi on auscultation. Chest X-ray showed white-out left lung [Figure 1]a. She had no history of fever, cough, breathlessness, or chest pain at present. Pulmonary medicine consultation was sought. Contrast-enhanced computed tomography revealed, the complete collapse of the left lung with cystic broncheictatic changes and ipsilateral mediastinal shift along with that a thin-walled (4.0 mm in thickness) cavity of size 1.4 cm × 2.5 cm × 3.3 cm in the postero-basal segment of left lower lobe [Figure 1]b and [Figure 1]c. A restrictive lung disease was observed on the pulmonary function test. Hence, high-risk consent was obtained before surgery. Airway examination, Mallampati Grade-3 with mouth opening 5 cm. All other examinations were within the normal limits. Preoperative vitals were Heart rate (HR) - 94/min, blood pressure (BP) - 142/82 mm Hg, SPO2-94%. Arterial blood gas analysis (ABG), Ph - 7.32, PCO2-45 mm Hg, PO2-86 mm Hg, HCO3-23.7 mEq/l.
|Figure 1: (a) Chest X-ray showing white out left lung, (b and c) contrast enhanced computed tomography showing, complete collapse of left lung with cystic broncheictatic changes and ipsilateral mediastinal shift with a thin walled cavity in the postero-basal segment of left lower lobe|
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On the day of surgery nil per oral status confirmed and the patient was shifted to the operation room. Ringer lactate solution was infused using 20G intravenous (IV) cannula. American Society of Anesthesiologists (ASA) monitors including electrocardiography, noninvasive BP, SPO2 were attached. Preoxygenated with 100% oxygen for 3 min. Anaesthesia induced with IV fentanyl - 1.5 μg/kg, midazolam - 0.05 mg/kg, propofol - 2 mg/kg, vecuronium - 0.1 mg/kg. During intubation, difficulty was encountered with a Cormac-Lehane grade-3 and the trachea was secured on the second attempt using bougie with endotracheal tube - 7.5 mm/cuffed/polyvinyl chloride. Bilateral air entry checked which was grossly diminished on the left side. Meantime patient's desaturated rapidly to 88% during intubation attempt and became 98% after starting mechanical ventilation. Anesthesia was maintained with O2:N2O - 50:50, sevoflurane and intermittent vecuronium. Patient was put on volume-controlled mode and end-tidal CO2 targeted between 32 and 35 mm Hg (tidal volume-6 ml/kg, respiratory rate [RR] - 12–14/min, I: E-1:1.5, positive end-expiratory pressure (PEEP) - 5 cm H2O). Half an hour after the creation of pneumoperitoneum the SPO2 decreased gradually from 100% to 91% (ABG, ph - 7.21, PCO2-56 mm Hg and PO2-88 mm Hg, HCO3-25.7 mEq/l). Hence, the ventilatory mode was changed to pressure-controlled mode to avoid volutrauma with pressure support of 20 cm H2O, RR - 16/min, PEEP-6 cm H2O and I:E - 1:1. The surgery team was requested to create pneumoperitoneum slowly with a maximum limit of 12 mm Hg. Following which SPO2 increased to 98%. Further, intra-operative course was uneventful. After successful completion of surgery, residual neuromuscular blockade was reversed and the patient was extubated in fully awake state obeying command. Postoperative course was also uneventful, vitals – HR - 88/min, BP - 138/72 mm Hg, SPO2-94% and ABG revealed, ph - 7.33, PCO2-44 mm Hg, PO2-90 mm Hg, and HCO3-23.1 mEq/l.
Lung fibrosis is associated with decreased lung compliance and low arterial oxygen reserve, which was evident from the preoperative saturation and rapid desaturation during intubation in this case. Laparoscopic surgery with pneumoperitoneum can further compromise lung function. However, laparoscopic cholecystectomy is a better surgical choice than open cholecystectomy in patients with lung fibrosis. Damiani et al. and Bablekos et al., concluded that laparoscopic cholecystectomy was associated with better lung function than the open procedure. Pneumoperitoneum with reverse Trendelenburg position can lead to ventilation-perfusion mismatch, decreased functional residual capacity, atelectasis, hypoxemia, and hypercarbia. It can also lead to increase in airway resistance and reduced lung compliance. Hence, a lung-protective ventilation strategy was employed to limit inspiratory pressure to 30 mm Hg and to avoid barotrauma. However, patient desaturated after the creation of pneumoperitoneum, which was managed by switching the ventilation strategy from lung-protective ventilation to pressure-controlled ventilation and by requesting the surgeon to slow down the rate of gas insufflation. Although supraglottic airway may be used, endotracheal intubation was preferred in this case as it provides better airway control with decreased risk of gastric aspiration.
To conclude, this case signifies the challenges encountered during the management of a patient with lung fibrosis undergoing laparoscopic surgery. Patients with lung fibrosis are prone to frequent desaturation due to poor lung function. Hence, we have to be vigilant while managing such patients. In addition, pressure-controlled ventilation can be a useful option in case of intra-operative desaturation.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initial s will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
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