Pulmonary Hemorrhage

General Data

A.M. 4 month old male Filipino Catholic Born and currently residing in Trece Martires admitted on May 13, 2012

Chief Complaint

cleft lip and palate

HPI
The patient was born term with cleft lip
and palate

(-) cough/colds (-) fever (-) vomiting (+) good appetite/activity

Past Medical History

(-) respiratory tract infection (-) seizures (-) asthma (+) allegedly allergic to cows milk (-) previous surgery

Family Medical History

(-) asthma/allergies (-) blood dyscrasia (-) hypertension (-) DM

Birth and Maternal History

Born term to a 21G1P1 (1001) via VSD at a lying in hospital

(-) antenatal sickness by mother

(-) intake of abortaficient unremarkable post natal history (+) vit K given (+) Hep B, BCG given

Physical Examination

General Survey: Awake, good activity, not in cardiorespirtory distress

Vital Signs

HR 108

RR 24
Temp 36.5

Weight 5.5kg

Physical Examination
SHEENT (+) good turgor (-) pallor, jaundice, lesions (+) cleft lip and palate, complete normocephalic pink palpebral conjunctivae

Physical Examination

Chest and Lungs

symmetrical chest expansion

(-) retractions
clear breath sounds

CVS normal rate regular rhythm (-) murmurs

Physical Examination

Abdomen

non distended normoactive bowel sounds soft non tender

Extremities Full and equal peripheral pulses

no edema
no cyanosis

Physical Examination
CNS GCS 15 Motor: 5/5 on all extremities

Laboratories

CBC

hgb 102 hct 0.31 wbc 11.1

Protime Time 11.4 seconds 110.5% activity INR 0.88

Partial Thromboplastin Time 43.2 seconds Ratio 1.42

Laboratories
Chest Xray non-specific pneumonitis

Impression

Cleft lip and palate

Plan
cheiloplasty under Geta-inh-Jackson
Rees

Transferred to PACU hooked to mechanical ventilator with the following settings

FIO2 - 80 RR 40 PIP 14/4

Salbutamol alternating with Ipratropium + salbutamol (Duavent) Q2

diphenhydramine 5mg IV q6 cefuroxime 175mg IV q8 Paracetamol 300mg IV Q6

Fentanyl 15mcg SIVP q4

ABG 1 hour after hooking to mechanical ventilator Chest xray AP/L

ABG done 1 hour after hooking to mechanical ventilator

pH 7.29 PCO2 23 PO2 110 HCO3 10.8 B.E. 14.5 02 sat 98%

correction done with NaHCO3 10meqs 30min SIVP then 14meqs x 4 hours

 chest xray no significant interval changes noted

compared to study from 5/08/2012

Course in the Wards

6 hours post op

(+) improving activity hr 140 rr 40 (assisted), temp 36.5C O2 sat 100% (-) alar flaring (-) retractions (+) minimal rales (+) bibasal ronchi (+) good pulses 30 (spontaneous)

Course in the Wards

12 hours post op

HR 50-60 RR 40 (A/C mode) O2 sat 60-70% Temp 36.5C (+) poor activity (+) weak pulses (+) respiratory distress (+) alar flaring (+) retractions (-) breath sounds

Course in the Wards

12 hours post op

patient reintubated

CPR done
blood noted per orem

(+) blood clotted per half ET

chest xray done repeat CBC with PC PT, PTT

patient was revived after CPR

HR O2 sat RR

Course in the Wards

CBC

hgb 93 hct 28 wbc 4.2 PC 652,000

Protime 15.9 sec 79.2% activity INR 1.36

Blood transfusion of 80cc PRBC started

Chest Xray

more opaque lungs but with areas of airbronchogram

13 hours post op

GCS 3

HR 216
RR 60 assisted temp 37.3C O2 sat 78% (+) respiratory distress (+) retractions (+) ronchi

(+) crackles on both lung fields

(+) poor pulses (+) seizures dopamine drip started Vit K given diazepam given

Course in the Wards

25 hours post op

(+) poor activity GCS 3

HR 216
RR 60 assisted temp 37.3C O2 sat 78% (+) respiratory distress (+) retractions (+) crackles on both lung fields (+) poor pulses

Course in the Wards

30 hours post op

GCS 3 HR 0

RR 60 assisted
temp 35C O2 sat - no reading (+) poor activity (+) retractions (+) respiratory distress (+) crackles on both lung fields (+) poor pulses patients parents opted DNR

Final Diagnosis
acute respiratory failure secondary to
pulmonary hemorrhage

Discussion

Discussion
A.M. 4month old male unremarkable preoperative history underwent cheiloplasty under GETAINH-Jackson Rees

had bronchospasm after extubation

Discussion

Bronchospasm can be secondary to

aspiration anaphylaxis unknown history of preoperative respiratory tract infection undiagnosed asthma post extubation spasm

Discussion
extubation triggering agent bronchospasm hypoxia metabolic acidosis

reintubation

assisted ventilation pulmonary hemorrhageanemia respiratory distress hypoxia seizures (clotted blood per ET) deterioration/CP arrest hypoxia

Bronchospasm
manifests during anesthesia as expiratory wheeze/no breath sounds
on auscultation

prolonged expiration increased inflation pressure during

intermittent positive pressure ventilation

Bronchospasm
may appear as an entity on its own or
be a component of another problem

Bronchospasm
Signs increasing circuit pressure desaturation wheeze rising ETCO2 and prolonged
expiration

reduction in tidal volume

Bronchospasm

Think of

anaphylaxis/allergy to drugs/IV fluids/latex airway manipulation/irritation/secretions esophageal/endobronchial intubation pneumothorax inadequate anesthetic depth or failure of anesthetic delivery system

Bronchospasm
if intubated endobronchial position esophageal position if mask/LMA in use laryngospasm/airway obstruction regurgitation/vomit/aspiration

Causes of bronchospasm or wheeze during the induction phase of anesthesia

airway irritation anaphylaxis misplacement of endotracheal tube aspiration pulmonary edema following failed
intubation

Causes of bronchospasm or wheeze during the maintenance phase of anesthesia

anaphylaxis endotracheal tube or ventilator problem

aspiration
pneumothorax pulmonary edema profuse bronchial mucus drug induced

Causes of bronchospasm or wheeze during the emergence/recovery phase of anesthesia

anaphylaxis inadvertent extubation extubation spasm aspiration pulmonary edema

Bronchospasm

Emergency management

100% oxygen cease stimulation/surgery request immediate assistance deepen anesthesia give beta adrenergic agonists (salbutamol) corticosteroids

Pulmonary Hemorrhage
rare, but catastrophic complication with
a high risk of morbidity and mortality

symptoms of respiratory distress hemorrhagic pulmonary edema is the

source of blood in many cases

Pulmonary Hemorrhage

incidence is increased in association with

acute pulmonary infection severe asphyxia hyaline membrane disease assisted ventilation PDA congenital heart disease erythroblastosis fetalis hemorrhagic disease of the newborn

thrombocytopenia
inborn errors of ammonia metabolism cold injury

Pulmonary Hemorrhage
treatment blood replacement PEEP suctioning to clear the airway intratracheal administration of
epinephrine