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Diffuse Alveolar Hemorrhage After Orotracheal Extubation Probably Induced by Sevoflurane Inhalation
Hemorragia alveolar difusa tras extubación orotraqueal probablemente inducida por la inhalación de sevoflurano
Mauro Carvalho Mendonça
, João Bettencourt Abreu, Karina Gama
Corresponding author
Anesthesiology Department, Central Hospital of Funchal, Av. Luís de Camões 6180, 9000-177 Funchal, Portugal
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The anomalous bronchial artery originates two bronchial arteries, right and left. The five arrows point to 1: the origin at the aorta; 2: the first branch, which is a normal right intercostobronchial branch; 3: the second branch, which is an aberrant bronchial trunk; 4 and 5: the two vessels originate from the bronchial trunk to form right and left bronchial arteries.</p> <p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">B – Computerized tomography reconstruction arteriography view showing the tortuosity of the anomalous bronchial artery described in a (<elsevierMultimedia ident="202108020528005491"></elsevierMultimedia>).</p> <p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">C – Dynamic image showing the anomalous bronchial artery tortuous path around the left main bronchus.</p> <p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">D – Endovascular embolization of the abnormal vessel, occluded with 12 microcoils.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Filipa Marujo, Filipe Veloso Gomes, Fernando Rodrigues, Pedro Flores" "autores" => array:4 [ 0 => array:2 [ "nombre" => "Filipa" "apellidos" => "Marujo" ] 1 => array:2 [ "nombre" => "Filipe Veloso" "apellidos" => "Gomes" ] 2 => array:2 [ "nombre" => "Fernando" "apellidos" => "Rodrigues" ] 3 => array:2 [ "nombre" => "Pedro" "apellidos" => "Flores" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0300289620303392?idApp=UINPBA00003Z" "url" => "/03002896/0000005700000008/v1_202108020527/S0300289620303392/v1_202108020527/en/main.assets" ] "itemAnterior" => array:19 [ "pii" => "S0300289621000053" "issn" => "03002896" "doi" => "10.1016/j.arbres.2020.12.026" "estado" => "S300" "fechaPublicacion" => "2021-08-01" "aid" => "2712" "copyright" => "SEPAR" "documento" => "article" "crossmark" => 1 "subdocumento" => "sco" "cita" => "Arch Bronconeumol. 2021;57:546" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "es" => array:11 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Imagen clínica</span>" "titulo" => "Doble fístula tras cavitación de adenocarcinoma pulmonar tratado mediante termoablación con microondas. Una complicación muy infrecuente" "tienePdf" => "es" "tieneTextoCompleto" => "es" "paginas" => array:1 [ 0 => array:1 [ "paginaInicial" => "546" ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "Double Fistula After Cavitation of Lung Adenocarcinoma Treated by Microwave Thermal Ablation. An Exceedingly Rare Complication" ] ] "contieneTextoCompleto" => array:1 [ "es" => true ] "contienePdf" => array:1 [ "es" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figura 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 778 "Ancho" => 1000 "Tamanyo" => 127522 ] ] "descripcion" => array:1 [ "es" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Radiografía de tórax, proyección PA (A). Extenso enfisema subcutáneo en pared torácica derecha y región supraclavicular y cervical, junto con neumomediastino (flechas). Masa mal delimitada en lóbulo superior derecho (asterisco), en aparente comunicación con un bronquio para dicho lóbulo (puntas de flecha). TC de tórax sin contraste intravenoso, ventana de parénquima pulmonar. Reconstrucciones multiplanares en plano coronal (B) y axial (<span class="elsevierStyleSmallCaps">C</span>), con proyección de mínima intensidad (D). Se muestra con claridad la cavidad aérea rodeando la masa tratada (puntas de flecha en B y C), en comunicación con una rama bronquial para dicho lóbulo (punta de flecha en D), así como neumomediastino (flechas blancas) y extenso enfisema subcutáneo de predominio en pared costal derecha. Llama la atención un gran lóculo de gas en la pared torácica adyacente a la cavidad postermoablación, que sugiere la existencia de comunicación entre ambas cavidades (asterisco en C y D). También se observan signos de enfisema centrolobulillar de predominio en lóbulos superiores.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Antonio Jesús Láinez Ramos-Bossini, Eduardo Ruiz Carazo, Genaro López Milena" "autores" => array:3 [ 0 => array:2 [ "nombre" => "Antonio Jesús" "apellidos" => "Láinez Ramos-Bossini" ] 1 => array:2 [ "nombre" => "Eduardo" "apellidos" => "Ruiz Carazo" ] 2 => array:2 [ "nombre" => "Genaro" "apellidos" => "López Milena" ] ] ] ] ] "idiomaDefecto" => "es" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S1579212921001907" "doi" => "10.1016/j.arbr.2021.05.018" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1579212921001907?idApp=UINPBA00003Z" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0300289621000053?idApp=UINPBA00003Z" "url" => "/03002896/0000005700000008/v1_202108020527/S0300289621000053/v1_202108020527/es/main.assets" ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Clinical Image</span>" "titulo" => "Diffuse Alveolar Hemorrhage After Orotracheal Extubation Probably Induced by Sevoflurane Inhalation" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "547" "paginaFinal" => "548" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Mauro Carvalho Mendonça, João Bettencourt Abreu, Karina Gama" "autores" => array:3 [ 0 => array:4 [ "nombre" => "Mauro Carvalho" "apellidos" => "Mendonça" "email" => array:1 [ 0 => "mauro.carvalho.mendonca@gmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "João Bettencourt" "apellidos" => "Abreu" ] 2 => array:2 [ "nombre" => "Karina" "apellidos" => "Gama" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Anesthesiology Department, Central Hospital of Funchal, Av. Luís de Camões 6180, 9000-177 Funchal, Portugal" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Hemorragia alveolar difusa tras extubación orotraqueal probablemente inducida por la inhalación de sevoflurano" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1199 "Ancho" => 1267 "Tamanyo" => 166514 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">(a, b) Axial and coronal views of thoracic computed tomography performed after admission in intensive care unit; (c) lesion observed in bronchoscopy on day five after admission. (d) Coronal view of thoracic computed tomography performed 15 days after the first tomographic evaluation.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">We report a case of a 38 years old male, smoker, without previous known pathologies and any assumed toxic habits. Pre-operative tests including coagulation, were normal. He was submitted to supraspinatus raffia through shoulder arthroscopy, under balanced general anesthesia with inhaled Sevoflurane. Orotracheal intubation (OI), performed with Macintosh laryngoscope, was smooth and easy with a 7.5<span class="elsevierStyleHsp" style=""></span>mm reinforced tube. No trauma or other complications were reported during OI or surgery. Two minutes after extubation, the patient presented laryngospasm, desaturation, and massive hemoptysis. He was immediately reintubated and admitted to Intensive Care Unit, where a first diagnostic bronchofibroscopy was performed, reporting distal massive hemorrhage without any visible focus or trauma in the airways. Thorax Computed Tomography showed diffuse alveolar hemorrhage (DAH) and excluded pulmonary embolism (PE). After five days with OI, a new bronchofibroscopy showed a lesion in the posterior wall of trachea. An autoimmune screening was performed and excluded vasculitis. Patient was discharged after two weeks and a third bronchofibroscopy was made after one month, displaying good evolution.</p><p id="par0010" class="elsevierStylePara elsevierViewall">In this case there were several different diagnostic possibilities: Airway trauma, PE, autoimmune diseases, negative pressure pulmonary edema (NPPE) and Sevoflurane induced DAH. The lesion found in the second bronchofibroscopy was not seen in the first exam, which could be related to the use of high pressure endotracheal cuff, during the five days of OI. In the other hand, in the first bronchofibroscopy, the presence of an orotracheal tube may have hindered the observation of tracheal trauma. NPPE after an upper airway obstruction such as laryngospasm is another plausible hipothesys.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">1</span></a> Still, preexisting pulmonary damage from smoking and administration of the irritating inhaled anesthetic Sevoflurane, could lead to DAH.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">1</span></a> There are, in literature, a few case reports<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">1,2</span></a> of hemoptysis related to the association of inhaled Sevoflurane and NPPE after extubation, and this might be another one (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Even though we didn’t find an unequivocal diagnosis, with this case we wanted to highlight the chance of Sevoflurane induced DAH or NPPE as hypothesis for immediate postoperative hemoptysis.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1199 "Ancho" => 1267 "Tamanyo" => 166514 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">(a, b) Axial and coronal views of thoracic computed tomography performed after admission in intensive care unit; (c) lesion observed in bronchoscopy on day five after admission. (d) Coronal view of thoracic computed tomography performed 15 days after the first tomographic evaluation.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:2 [ 0 => array:3 [ "identificador" => "bib0015" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Negative pressure pulmonary edema-related diffuse alveolar hemorrhage associated with Sevoflurane and cigarette smoking" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "D. Hao" 1 => "S. Basnet" 2 => "S. Melnick" 3 => "J. Kim" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1080/20009666.2019.1608140" "Revista" => array:6 [ "tituloSerie" => "J Community Hosp Intern Med Perspect" "fecha" => "2019" "volumen" => "9" "paginaInicial" => "247" "paginaFinal" => "251" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/31258867" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0020" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Diffuse alveolar hemorrhage induced by sevoflurane" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "C.A. Kim" 1 => "R. Liu" 2 => "D.W. Hsia" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1513/AnnalsATS.201402-067LE" "Revista" => array:6 [ "tituloSerie" => "Ann Am Thorac Soc" "fecha" => "2014" "volumen" => "11" "paginaInicial" => "853" "paginaFinal" => "855" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24936702" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/03002896/0000005700000008/v1_202108020527/S0300289621000144/v1_202108020527/en/main.assets" "Apartado" => array:4 [ "identificador" => "21422" "tipo" => "SECCION" "es" => array:2 [ "titulo" => "Clinical Images / Imágenes clínicas" "idiomaDefecto" => true ] "idiomaDefecto" => "es" ] "PDF" => "https://static.elsevier.es/multimedia/03002896/0000005700000008/v1_202108020527/S0300289621000144/v1_202108020527/en/main.pdf?idApp=UINPBA00003Z&text.app=https://archbronconeumol.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0300289621000144?idApp=UINPBA00003Z" ]
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