We present an interesting
case of congenital lung cysts disease anesthetized by sevoflurane inhalation
 demonstrated unsuitable condition for intubation. This may be reflection of
defective physiological transfer of inhalational agents. The situation remedied
by supplement of ketamine and rocuronium for intubation then inhalation
continued with sevoflurane
A 27 weeks gravid premature
girl, weighing 1000 g at birth, delivered to G7 P6+1 mother who had eclampsia
at 72 weeks of gestation.
At the age of 4 weeks the
girl was intubated and ventilated for 26 days due to respiratory impairment.
Later she was diagnosed as a
(1) Retinopathy of prematurity
(2) Congenital bronchopulmonary dysplasia
No other medical diseases
She was referred from
peripheral hospital to ophthalmic unit at King Fahad Medical City for laser
surgery to control congenital retinopathy.
The girl was admitted to the
NICU, and investigated and found to have right lung cyst. The treating
physician asked an anesthesia consultation for laser surgery.
The girl was kept in an
incubator. She was breathing spontaneously, active and on oxygen supplements 4
L per minute via mask. Auscultation of the chest did not elicit abnormality.
Vital signs; HR: 170 b per minutem. Chest was quite with breathing sounds.
Blood pressure: 85/40 mmHg. RR-35 b/m.
She was on oral feeding.
showing: urea: 1.4 mmol -1. creatinine 19.0
µmol.l -1 . K: 5.5 mEq.l-1 Na :141 mEq.l-1Hb:11 g.dl-1 platelets:497 x10.e9.l-1 Coagulation profile pt:12.4,
Pulmonologist who cared for
the chest condition advised that the lung cysts are small in size. A pediatric
surgical consultation for management of the lung cyst obtained, and advised
that there is no need for urgent surgery, but advised that if pneumothorax
develops during laser surgery then immediate intervention should take place.
On 18-8-2007 Anesthesia took
Inhalational induction using
sevoflurane, Anesthesiologist took long induction before laryngoscopy and tried
intubation but found the condition was not proper for intubation, the girl was
“fighting,” so since she was on sevoflurane inhalation supplemental ketamine
was given intravenously in dose 0.5 mg kg-1. Atropine - 0.1mg given as well then Recuronium-
3 mg was injected, so the trachea was intubated successfully. The respiration
resumed with the tube in place.
Anesthesia maintained on
sevoflurane 2% in Air:Oxygen mixture.
Respiration was spontaneous
with occasional ventilatory manual support.
Finally at the one hour
procedure, the girl was extubated after she recovered completely and was sent
back to NICU on 4L O2 with SpO2 100%. Later on, she was discharged
to primary hospital on 28.8.2007 in good condition.
Adenomatoid Malformation (CCAM) was reviewed recently . It is a rare
congenital malformation of the lung representing 25% of congenital lung
malformations and 95% of congenital lung lesions [2, 3]. This lesion occurs
more often in males (1.8:1), and is primarily unilateral, but may occur
CCAM with severe respiratory
dysfunction from birth was reported and the anesthetic coerce was dependent on
sevoflurane inhalation and spontaneous respiration. It was 5-day-old-boy with
CCAM underwent removal of a large cyst which was present at lower lobe of right
lung. Anesthesia was induced slowly and maintained with oxygen and sevoflurane.
Severe airway obstruction occurred transiently by the secretion from the lung
cyst. Thereafter, the surgery was completed safely and his postoperative course
was uneventful .
A recent report describing a left pneumonectomy
performed on a six week-old female infant suffering from respiratory distress
related to cystic changes affecting the entire left lung. Anesthesia was
induced with sevoflurane in oxygen and spontaneous ventilation was maintained
until intubation of the right main bronchus was secured. The postoperative
course was uneventful. The pathological diagnosis was pulmonary interstitial
emphysema [6, 7]. In the case we are presenting; inhalation of sevoflurane given
for long period, the patient did not relax enough for intubation though high
concentration 6% sevoflurane and three minutes has passed. Ketamine supplement
and recuronium were used to secure the airway. We conclude that induction of
these cases for surgery is adopting inhalational method to prevent cysts from
distention if IPPV is used. But the lung pathology may elongate the inhalational
induction for manipulation of the airway. Alternatively intravenous induction
with anesthetics and muscle relaxant would control the airway. Also gentile
ventilation would provide oxygenation and elimination of carbon dioxide.