Negative Pressure Pulmonary Edema in an Infant
Mohammad Abbasian, M.D.
Department of Anesthesiology, University of Florida, Gainesville, Florida
ABSTRACT
Presentation: The case was that of a 2-month-old African American boy
admitted for trabeculotomy for congenital glaucoma. He was scheduled for
same day pre-operative evaluation. The infant was full term, with normal
vaginal delivery, no allergies, 6 kg, and had a normal pediatric airway. His
blood pressure was 85/40 mm Hg, heart rate was 155 beats/min, temperature
was 36.8ºC, lung bilaterally were clear to auscultation He was sedated with
intramuscular ketamine, 4 mg/kg, and glycopyrrolate 0.01 mg/kg for
intraocular pressure measurement. A 22-ga intravenous catheter was inserted
and a laryngeal mask airway 1.5 was placed. Anesthesia was maintained with
sevoflurane and nitrous oxide. The case was uneventful with the patient
breathing spontaneously at the end of surgery. The LMA was removed and he
developed laryngospasm, which we were unable to stop using continuous
positive airway pressure (CPAP). We administered succinylcholine, 4 mg, and
atropine and eventually intubated him. After intubation he had frothy
pinkish secretions coming out of the ETT, which was diagnosed as negative
pressure pulmonary edema. Furosemide, 6 mg, was administered intravenously
and the patient was transported to the PICU and started on mechanical
ventilation with PEEP of 5 cm H2O. A chest radiograph confirmed pulmonary
edema. The patient was maintained on mechanical ventilation overnight and
extubated the next morning and discharged home the following day.
Discussion: This case is interesting in that it is one of the youngest
reported patients to develop postoperative obstructive pulmonary edema. The
youngest reported case was a one-month-old infant with obstruction of the
ETT during transport. This case also shows the higher association of
laryngospasm and LMA in children under 3 years old. Finally, this
presentation also shows that although infants this young might not have
significant muscle mass, they may still develop intra-thoracic negative
pressure sufficient to cause pulmonary edema.
