Acute pulmonary capillary leak syndrome during elective surgery under general anesthesia

Abstract

A 75-year-old previously healthy man presented for elective resection of rectal cancer under general anesthesia. Six days before the operation, he had a high-grade fever, and elevated leukocyte count and C-reactive protein concentration, but this was resolved by an intravenous antibiotic. His condition was well controlled before the operation. Soon after the operation started, severe hypoxemia emerged, with low arterial pressure. Fiberoptic bronchoscopy demonstrated a massive amount of plasma-like edema fluid; the total amount of suctioned fluid was approximately 800 ml at the end of the surgery. This acute pulmonary edema appeared to be due to increased permeability rather than pulmonary congestion as indicated by chest radiography, pulmonary artery occlusion pressure, echocardiogram, and the protein-rich edema fluid. Elevated concentrations of the proinflammatory cytokines, interleukin (IL)-6 and IL-8, in both plasma and the pulmonary edema fluid, suggested a possible role of systemic and pulmonary inflammation in the development of this acute pulmonary capillary leak. According to the "two-hit" hypothesis, the bacterial infection preceding the operation may have primed the immune cells, and the following surgical stress may have then triggered rapid progression of acute respiratory distress syndrome. We should keep in mind that, especially following sepsis, sudden massive pulmonary capillary leak can occur during elective surgery, even though the patient's condition is well controlled.

The effect of crystalloid infusion on body water content and intra-abdominal pressure in patients undergoing orthopedic surgery under spinal anesthesia

“…9,24,25 Surgery-related injury induces the release of proinflam- matory cytokines, such as tumor necrosis factor α (TNFα), vascular endothelial growth factor (VEGF), many interleukins, histamine, and E-selectine, which may disturb vascular permeability, and increase fluid shift into the extravascular space. 26,27 Moreover, surgery-related perioperative stress induces the release of antidiuretic hormone, cortisol and corticotrophins, and stimulates the renin-angiotensin-aldosterone system to increase salt and fluid retention. 28,29 Therefore, a surgery-induced increase in vascular permeability and hormone-dependent fluid retention provoke perioperative tissue edema independently of fluid infusion.…”

Systemic capillary leak syndrome (Clarkson's disease) during elective pylorus-preserving pancreaticoduodenectomy: case report

“…SCLS is diagnosed clinically after exclusion of wide variety of diseases that cause systemic capillary leak such as infections, hereditary angioedema, chemotherapy, malignancy, drugs, anesthesia, and surgery with laboratory evidence of the plasma leak. 4 , 6 , 7 , 8 Hemoconcentration and hypoalbuminemia are the cornerstones of the diagnosis. Dhir et al has reported laboratory features of SCLS, that hematocrit was recorded to be high, 63.5±8.65%; serum albumin was mentioned to be low to 1.67±0.66 g/dl.…”

Non-cardiogenic pulmonary oedema after neostigmine given for reversal: A report of two cases

“…According to the “two hit hypotheses”, the bacterial infection preceding the operation may prime the immune cells and the following surgical stress may then trigger sudden massive pulmonary capillary leak leading to ARDS during elective surgery even though the patient’s condition is well controlled. [7]…”

“…[2] Less appreciated is the fact that various drugs, either taken as standard therapy or as an overdose, may precipitate NCPE. [7] Little is known about the mechanisms involved in drug related NCPE.…”