2 CASE REPORT
A 78-year-old male patient diagnosed with spinal stenosis was admitted to undergo unilateral laminectomy with bilateral decompression. The patient had been diagnosed with hypertension four years earlier and asthma more than 70 years earlier, and was prescribed fluticasone furoate and vilanterol inhalers for the treatment of asthma; however, these medications were not used consistently. The results of pulmonary function tests were FVC 2.53 L (61%), FEV1 1.37 L (52%), and FEV1/FVC 54, and chest radiographs showed subsegmental atelectasis in the left lower lobe and mild cardiomegaly (Fig. 1). Transthoracic echocardiography performed prior to surgery showed concentric left ventricular hypertrophy, trivial mitral regurgitation, and a mild relaxation abnormality, with other findings within normal limits. As premedication, hydrocortisone 100 mg was administered on the morning of surgery. Lung sounds confirmed after the patient entered the operating room were normal, and anesthesia was initiated after prophylactic administration of salbutamol inhalants. General anesthesia was induced with thiopental 250 mg and fentanyl 100 mcg, and the patient intubated without special difficulty after administration of rocuronium 50 mg. Anesthesia was maintained at 50% N2O and 5–7% desflurane. The operation was performed with the patient in the prone position, and there were no special events during the operation. The arterial blood gas analysis (ABGA) performed during the operation showed FiO2 0.5 to pH 7.420, pO2 242.5, pCO2 36.7, and base excess - 0.6, and hemoglobin level was 12.2 g/dl. At the end of the operation, sugammadex 200 mg was administered for reversal of muscle relaxation, the patient’s position was changed from prone to supine under deep anesthesia, and the bispectral index (BIS) score at that time was in the 40. Subsequently, several aspiration attempts were made to remove the secretions from the trachea and oral cavity in order to manage the tracheal tube, but the patient was clenching his teeth and did not open his mouth. At this time, airway obstruction occurred for several minutes, making ventilation difficult. Oxygen saturation decreased by 40% on pulse oximetry even though 50% of oxygen were provided and the concentration of inhalation anesthetics were not reduced. An additional 200 mg sugammadex was administered owing to severe airway obstruction caused by the patient’s clenching his teeth. After a few minutes, the patient stopped clenching his teeth, but a large amount of bloody discharge from the endotracheal tube was observed. Furosemide 40 mg was administered immediately based on suspected negative pressure pulmonary edema due to airway obstruction. The patient was ventilated with 100% oxygen, but the oxygen saturation was maintained at 90% or less. Chest imaging (Fig. 2) performed after transfer to the intensive care unit revealed haziness of the entire right lung, and bronchoscopy (Fig. 3), showed bloody secretions with red bubbles in the right lung. However, no active bleeding or endobronchial lesions were found. ABGA performed after transfer to the intensive care unit showed pH 7.30, pO2 72.9, pCO2 40.6, and HCO3 20.1, (FiO2 1.0) with hemoglobin of 11.4 g/dl. On the day of surgery, norepinephrine and vasopressin were used because the patient’s blood pressure decreased in the intensive care unit. Tranexamic acid and methylprednisolone were administered for pulmonary hemorrhage and pulmonary edema. Extubation was performed on the 8th postoperative day (POD) and the patient was transferred to the general ward on the 10th POD. On the subsequent chest radiography, most of the haziness of the right lung had disappeared (Fig. 4). The patient was discharged without any complications after a week after moving to the general ward.