Abbas S M, Hoda M Q.
Negative Pressure Pulmonary Edema: Case Report.
J Pak Med Assoc Jan ;54(7):396-8.

A 36 year old Gravida 5, para 3+1 presented with nine weeks history of amenorrhea with per vaginal bleeding and lower abdominal pain. On examination her blood pressure was 130/90 mmHg, pulse 80/min and temperature 37°C. Vaginal examination revealed a closed internal os and a bulky uterus. Uterine ultrasonography showed a very small intrauterine gestational sac and right ovarian cyst of 52x44mm. She was planned for laparoscopy and dilatation and evacuation under general anesthesia. She was classified as ASA IIE as she was slightly over weight. Twelve lead ECG was not performed since she was young and there was no history of cardiac illness on history/physical examination. She was anaesthetized by using rapid sequence induction technique with thiopentone sodium (5 mg/kg) and suxamethonium (1.5mg/kg) and her trachea was intubated with PVC endotracheal tube (ETT) size 7.5 mm ID without difficulty. Analgesia was provided with 80 mg of pethidine and atracurium 25 mg was used for muscle relaxation. The procedure lasted for approximately one hour. At the end of the procedure the inhalational anaesthetic was turned off and neostigmine 2.5 mg and atropine 1mg were administered to reverse the effect of neuromuscular blockade. Just before extubation she clenched her teeth on the ETT which resulted in complete airway obstruction. Her oxygen saturation on pulse oximetery decreased down to 54%. A Guedal oropharyngeal airway was introduced with some difficulty which relieved the obstruction. As the obstruction was relieved, copious amount of pink frothy fluid started flowing out of the ETT and oxygen saturation on pulse oximeter rose to 92% on 100% 02. Chest auscultation revealed bilateral coarse crepitations. At this stage working diagnoses included fluid over load, acute myocardial infarction or NPPE. Continued …

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