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Anrsthrsiology 2000; 93282-4 0 2000 American Society of Anesthesiologists, Inc. Lippincott Williams Sr Willcins, Inc. Negative-pressure Pulmonary Edema in a Child with Hiccups during Induction

Eckehard A. E. Stuth, M.D., * Astrid G. Stucke, M.D.,t Richard J. Berens, M.D. * Downloaded from http://pubs.asahq.org/anesthesiology/article-pdf/93/1/282/331607/0000542-200007000-00046.pdf by guest on 27 September 2021

PERIOPERATIVE hiccups in children are usually not as- sure ventilation of the lungs was applied without difficulty. The tra- sociated with significant morbidity. We report a case of chea was intubated with an uncuffed 5.5-mm nasotracheal tube. Sub- massive pulmonary edema that occurred after inhala- sequently, the patient underwent mechanical ventilation with 1% isoflurane in an air-oxygen mixture. Fentanyl, 2p&, and 0.1 mg tional induction of general anesthesia, which was com- glycopyrrolate were administered intravenously, and the table was plicated by vigorous regular hiccups. turned 90" for the dental procedure. During the next 20 min, blood pressure readings by Dinamapp (Critikon, Tampa, FL) were erratic. The Dinamapp intermittently dis played unexpectedly high pressures between 165/100 and 130/100 Case Report mmHg but eventually failed after prolonged cycling. Peripheral pulses could not be palpated, but a Doppler probe placed over the left An 8-yr-old,20-kg girl was scheduled to undergo dental restorations posterior tibia1 artery finally gave reproducible systolic readings be- and extractions as an outpatient. The patient had a history of seizures tween 90 and 120 mmHg. During the period of hemodynamic lability, and multiple ischemic strokes secondary to Moyamoya disease. She increased oxygen requirements developed in the patient. Repeated had undergone three previous operations during general anesthesia, chest auscultations revealed no evidence of wheezing or decreased or without anesthesia-relateddifficulties. asymmetric breath sounds. The capnogram remained unchanged with At the preoperative visit, she was aphasic and drooling. Significant end-tidal carbon dioxide values of 36-40 mmHg. After the oxygen left lower extremity weakness and diffuse fine motor deficits were also requirements reached 10096, the dental procedure was interrupted. present, but the patient was ambulatory. Endotracheal suction revealed more than 100 ml frothy pink fluid. The patient received 10 mg midazolam via G-tube as premedication. Chest radiography confirmed moderate pulmonary edema with a cen- After application of electrocardiogram leads and pulse oximetry, inha- tral pattern and normal heart size (fig. 1B). No effusions or focal lational induction with 70%nitrous oxide in oxygen and halothane was consolidationswere present. Intraoperative trdnsthoracic echocardiog- begun. Within seconds after the start of induction, vigorous hiccups, raphy showed good biventricular function but mild mitral regurgita- which were accompanied by tracheal tugging, developed in the pa- tion (+ 1) and mild pulmonary insufficiency. tient. Pulse oximetry showed a stable arterial saturation of 99-10076 The patient was administered a second dose of 15 mg rocuronium, throughout induction, and capnography did not show impairment of and reintubation was performed with a cuffed tube. The patient was gas exchange. Therefore, inhalational induction was continued, with sedated with 2 mg lorazepam and 60 pg fentanyl and transferred to the the child breathing spontaneously. The strong hiccups never ceased intensive care unit for postoperative ventilation with positive end- during approximately 10 min of induction. expiratory pressure. No inotropic or vasoactive agents were adminis- Finally, intravenous access was obtained and 20 mg rocuronium was tered at any time. A total volume of 800 ml lactated Ringer's solution administered intravenously. As neuromuscular blockade occurred, was infused over 4 h. The patient was extubated on the first postop- spontaneous ventilation and the hiccups stopped, and positive pres- erative day. Chest radiography showed almost complete resolution of the pulmonary edema and no focal areas of consolidation.The inspira- tory oxygen requirement normalized. A neurologic examination did * Associate Professor, Section of Pediatric Anesthesia and Depart- not show new deficits. Follow-up echocardiography showed resolu- ment of Anesthesiology. tion of all intraoperative abnormalities. Results of an allergy workup t Research Fellow, Department of Anesthesiology were negative for latex and ethylene oxide, but a skin-prick test Received from the Section of Pediatric Anesthesia, Children's Hos- showed a mild reaction to a 1:100 dilution of rocuronium (roc 1+, pital of Wisconsin, and the Department of Anesthesiology and Anes- histamine 3+>. thesia Research Service, Medical College of Wisconsin, Milwaukee, Wisconsin. Submitted for publication December 22, 1999. Accepted for publication March 21, 2000. Support was provided solely from Discussion institutional and/or departmental sources. Address reprint requests to Dr. Stuth: Children's Hospital of Wiscon- This child presented with fulminant pulmonary edema sin, Section of Pediatric Anesthesia, Milwaukee, Wisconsin 53226. that was most likely postobstructive and related to vig- Address electronic mail to: [email protected] orous hiccups during inhalation induction. Key words: Moyamoya; negative intrapleural pressure. Negative-pressure pulmonary edema (NPPE) occurs

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Fig. 1.01) Routine chest radiograph obtained several months before dental procedure shows that heart, pulmonary vessel size, and lung fields are normal. (B) Intraoperative chest radiograph shows moderate bilateral pulmonary edema but no pleural effusions or focal consolidation. Heart size is normal. An endotracheal tube is in the mid trachea just beyond the thoracic inlet. soon after relief of acute or chronic obstruction of the mations could have caused cerebral edema and subse- upper airway. It is commonly reported after laryngo- quent neurogenic pulmonary edema. Intraoperative spasm during induction or emergence from anesthesia. hypertension in the absence of strong surgical stimuli Markedly negative intrapleural pressures during airway has been described in patients with Moyamoya dis- occlusion cause increased venous return and increased Neurogenic pulmonary edema, however, usually left ventricular afterload. The increased hydrostatic pres- has a prolonged course with high mortality,' and our sure gradient in the pulmonary capillaries leads to trans- patient did not show any deterioration in neurologic sudation of fluid into the alveoli. Hypoxemia and a hy- status or evidence of cerebral edema after extubation. poxia-induced hyperadrenergic state further promote However, the observed hemodynamic instability with edema formation.',* peripheral vasoconstriction may be explained by a hy- In this patient, the rapid appearance and resolution of peradrenergic state that is associated with the develop- edema with supportive respiratory therapy alone make ment of postobstructive pulmonary edema.' Hypoxia of NPPE likely. the central nervous system is an important mediator for Lack of acidity of the suctioned fluid (pH 7.0)and the this reaction, and some central nervous system tissue centrally and bilaterally symmetric pattern of the edema hypoxia may have been present in this patient because on the chest radiograph argue against any significant Moyamoya disease impairs cerebral blood circulation. aspiration of gastric contents. The initial hypertensive Negative-pressure pulmonary edema has been de- phase and the complete absence of wheezing and other scribed without any clinical evidence of airway obstruc- signs of anaphylaxis are inconsistent with an allergic tion, which suggests that obstructive events can be sub- reaction. In addition, results of the allergy workup for tle.' Our patient had vigorous hiccups during 10 min of latex were negative and a second dose of rocuronium spontaneous breathing that only ceased with neuromus- before reintubation was tolerated well. cular blockade. Hiccups are brief, powerful inspiratory The most important differential diagnosis to NPPE in efforts synchronous with glottic closure.8 Studies in cats this patient seems to be neurogenic pulmonary edema. have shown that hiccups can cause negative intratho- Moyamoya diseuse is characterized by symmetric nar- racic pressures that are four times greater than during rowing of the anterior and middle cerebral arteries and normal inspiration.' Because NPPE can develop even the formation of hemodynamically insufficient collateral after minor airway obstruction,' we suggest that, in our We were initially concerned that the hemo- patient, the continuous, forceful hiccups were sufficient dynamic lability in this patient with intracranial malfor- to cause NPPE.

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We believe this is the first reported case of NPPE 3. Chaudhuri KR, Edwards R, Scott J, Brooks DJ, Rees A, Pusey CD: associated with hiccups during inhalational induction of Adult Moyamoya disease. BMJ 1993; 307:852-4 4. Manceau E, Giroud M, Dumas R: Moyamoya disease in children. A anesthesia. It is likely that more cases of unexplained review of the clinical and radiological features and current treatment. perioperative hypoxemia are related to unrecognized Child Nerv Syst 1997; 13:595-600 NPPE. We suggest that prolonged vigorous hiccups in 5. Brown SC, Lam AM: Moyamoya disease-A review of clinical anesthetized, spontaneously breathing patients who are experience and anesthetic management. Can J Anaesth 1990; 37: not intubated may not always be benign. 210-8 6. Kansha M, Irita K, Takahashi S, Matsushima T: Anesthetic man- Downloaded from http://pubs.asahq.org/anesthesiology/article-pdf/93/1/282/331607/0000542-200007000-00046.pdf by guest on 27 September 2021 agement of children with moyamoya disease. Clin Neurol Neurosurg References 1997; 99:S110-3 7. Simon Rp: Neurogenic pulmonary edema. Neurol Clin 1993; 1. Sulek CR, Kirby RR: The recurring problem of negative-pressure 111309-23 pulmonary edema. Cum Rev Clin Anesth 1998; 18:241-52 8. Oshima T, Sakamoto M, Arita H: Hiccuplike response elicited by 2. Lang SA, Duncan PG, Shephard DA, Ha HC: Pulmonary oedema mechanical stimulation of dorsal epipharynx of cats. J Appl Physiol associated with airway obstruction. Can J Anaesth 1990; 37:210-8 1994; 76:1888-95

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