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CASE REPORT: A Case of the “ Pink, Frothy Secretions ”

This case report discusses the epidemiology, symptoms, diagnosis, and treatment of Negative Pressure Pulmonary Edema (NPPE). It presents a detailed account of a patient's medical history, surgical procedure, and post-anesthesia recovery, highlighting the development of NPPE and its management.

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CASE REPORT: A Case of the “ Pink, Frothy Secretions ”

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  1. CASE REPORT: A Case of the “ Pink, Frothy Secretions” Sallie Poepsel, PhD, MSN, CRNA, APRN Director, AANA Region IV

  2. NO Financial interests to disclose

  3. Objectives: • Describe the epidemiology and contributing factors to Negative Pressure Pulmonary Edema (NPPE) in anesthesia practice • Identify the symptoms and precipitating signs of NPPE • Describe the algorithm to establish the differential diagnosis of NPPE • Using a case report, discuss the treatment and clinical management of NPPE

  4. NPPE Revisited • 1927 - Moore demonstrated in spontaneously breathing dogs exposed to resistive load. • 1942 - Warren et al first description of the pathophysiological correlation between creation of negative pressure and the development of pulmonary edema 

  5. Past Medical History: • Thisis a 70 yr. old white female with a known history of CAD and PE and S/P cardiac arrest July 23, 2012 in the ER; • revived with ACLS and intubation. • Transferred to Blessing hospital to the ICU and was started on a Dopamine drip. • Initial rhythm was bradycardia. • Patient was on a ventilator for approx. 1 week. • By the 8th day post cardiac event: responsive to verbal commands. • While at Blessing other findings included Pulmonary Edema/CHF most likely associated with severe MR. complications of SVT/Afib-flutter requiring Amiodarone. • Cardiac cath was performed on 8/3/12. • Transferred back to SCH for rehab.

  6. Hospital Course @ SCH • Allergies: Tetanus & Vitamin K • Medications: Levofloxacin; amiodarone; simvastatin, KCL tab ER, lansoprazole, ondansetron, tylenol • Past Medical History: Positive for CAD, severe MR, cardiac dysrhythmia, chronic CHF with echo showing est. EF of 35-40% (2/12) but down to 25% per Blessing Hospital; L PE , moderate pulmonary hypertension, anemia, kidney stones, rheumatoid arthritis and chronic back pain. • Past Surgical History: S/P cardiac stent (RCA and 50% lesion on the LAD); removal of corpus polyp with hysteroscopicpolypectomy and D & C, and lithotripsy.

  7. Hospital Course continued • Blood Transfusion for anemia (Hgb……. • EGD & Colonoscopy on 8/17/12 which revealed: mild gastritis sl. bleeding cecal mass; medium-sized pedunculated polyp which was removed

  8. Pre-operative Phase • Pre-anesthetic evaluation showed the following: Hgb: 10.7 Hct : 32.3 Platelets 79K PT/INR: 15.2/1.5

  9. Intra-operative Phase • Summary of Events • Patient was brought to the OR @ 0827 for R colectomy with primary anastomosis and adhesiolysis. • Pre-induction: Versed; Fentanyl • Induction: Etomidate 12 mg; Vecuronium 7 mg • Post-intubation: Arterial line for BP monitoring; Platelets • Pre-emergence: 1 unit PRBC;R IJ triple lumen • Emergence & extubation

  10. Intra-operative Phase: con’t • Intraoperative vital signs were unremarkable; surgery ended @1020; patient met extubation criteria following emergence from anesthesia, and was extubated in the OR, then transferred to level I PACU for post-anesthesia recovery. VS stable O2 Sat @ 99% enrouteto PACU

  11. Post-Anesthesia & Level I Recovery • Admited to PACU @ 1032 • Patient remained essentially stable and responsive. Had an episode of nausea with no vomiting and was treated with Zofran 4 mg; Aldrete score: 9 1100 - patient started “heaving”, followed by decreased RR followed by a drop in SpO2 from 99% to 17%

  12. Post Anesthesia…Con’t 1101-1110 loss of O2 Sats, (99% to 17%) apnea; carotid pulse present; Code Blue; ambuBag @12/min Narcan 0.1 mg IVP; BP 178/81 sinus brady (40’s) SpO2 @ 82% - 85%; pt opened eyes; did not follow commands; intubated w/7.0 ETT, placement confirmed auscultation; ETT secured; Fr 16 NG tube placed, repositioned & secured

  13. Post-Anesthesia..Con’t 1111 - 1120 Neostigmine 1 mg/0.5 Robinul IV; ETT aspirate pink & frothy; BP- 178/80-163/90; HR @138 (Esmolol 10 mg IV); Spo2 @ 95%- 98% con’tambu

  14. Post anesthesia… Con’t 1121 - 1130 Neostigmine 1 mg IV; Lasix 10 mg IV @1120; Bronchoscopy @ 1122-1124 w/ETT repositioning (re-intubation) VS - 145/67- 100 con’t ambu; Versed 2 mg IV & Bronch repeated; suctioned 175 ml; Lasix 10 mg IV @ 1129

  15. Post anesthesia….Con’t 1131 - 1135 VS- 156/70-124-87% (suctioning) con’t ambu @ 12L/min; PACU monitors enroute to ICU. O2 sats @ 98% prior to ICU transfer CX Ray & Labs: consistent with Pulmonary Edema

  16. ICU Phase: Post-Op Day 1-2 • Mechanical Ventilation • Con’t monitoring (i.e Arterial BP, EKG…etc & Inotropic support • Extubated next day; lungs significantly improved w/diuresis IS @ 1000ml • Art Line dcd; IS @ 1000ml • 8/31/12: Dopamine @ 1 mcg/kg/min with excellent VS Chemistries unremarkable Alert and oriented; Bowel sounds (+) taking more oral intake

  17. Post – Op Day 3 - 7 • Transferred from ICU; RIJ Central line dcd • Significant post-op improvement; weaned off O2 • Continuing PT & Rehab

  18. Differential DiagnosisTachypnea-Dyspnea- O2 desaturation-Crackles-Frothy Sputum Hypotension Swelling, Rash Bronchospasm ANAPHYLAXIS Elevated tryptase levels Consider….. New arrhythmias, ST changes Evidence of L HF CARDIOGENIC Echo Elevated Pulm Occlusion pressure

  19. Differential Diagnosis:Tachypnea-Dyspnea- O2 desaturation-Crackles-Frothy Sputum Consider….. Recent trauma/hemorrhagic brain injury Intracranial mass NEUROGENIC Associated with Acute Hypertension

  20. Differential DiagnosisConsider….. Evidence of acute airway obstruction i.e. laryngo/bronchospasm, Biting ETT ACUTE NEGATIVE PULMONARY PRESSURE EDEMA Fluid Overload Unintended Hypotonic Fluid administration FLUID MALDISTRIBUTION Hyponatremia, hypoosmolarity

  21. Upper Airway Obstruction Muller maneuver • More Negative Pressure • Pulmonary Blood Volume • Pulmonary Arterial Pressure • Transudation • Pulmonary Edema

  22. Pathophysiology: Acute NPPE highly negative intrathoracic pressure generation Venous return to the heart Pulmonary blood volume Pulmonary capillary permeability Redistribution of fluid after relief of obstruction into pulmonary interstitium

  23. CARDIAC OUTPUT HEART RATE x STROKE VOLUME CONTRACTILITY PRELOAD AFTERLOAD

  24. ACUTE NEGATIVE PRESSURE PULMONARY EDEMA Epidemiology: ~1 in 1000 patients receiving anesthesia 74% post-extubation 26% during initial airway management Contributing factors: airway obstruction - laryngospasm, bronchospasm - patient bites on tracheal tube - head & neck tumors *** Source:) Krodel et al (2010) Anesthesiology 113:1; pp.200-207 doi: 10.1097/ALN.0b013e3181e32e68

  25. Clinical Management • Airway/Respiratory Noninvasive Pressure Support (NPS) i.e supplemental O2, CPAP, pressure support -in cases of failing NPS, re-intubation; mech. Ventilation • Pharmacologic consider diuretics inhaled ß agonists • Outcome: Recovery in 12-48 hrs assuming appropriate supportive measures are taken

  26. Questions ???

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