Perioperative management of a 70 year-old patient with acute respiratory failure after prolonged surgery of fourteen hours

Hiroshi Hoshijima, Risa Takeuchi, Noriko Onuki, Hiroshi Nagasaka, Seiji Suzuki, Yoshihiko Miyata, Akihiko Hasegawa

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We experienced a case of perioperative management of a 70 year-old patient with acute respiratory failure complicated with frequent hypoxemic episodes during and after prolonged operation of 14 hours. Preoperatively, the patient was diagnosed with cancer of the palatine process of maxillar and was scheduled for maxillary block resection and bilateral radical neck dissection. He was diagnosed as having no medical problems in preoperative examinations except for PaO 2 84.2 mmHg, secondary to previous chemotherapy. No premedications were administered. ECG monitoring and peripheral hemoglobin saturation (pulseoxymetry) monitoring was established. An automated cuffed blood pressure measurement was placed on the right arm and set to record at 2.5-minute intervals. Before anesthetic induction, pulse-oximeter SpO 2 showed 100% at room air. Nitroglycerine and diltiazem were infused intravenously at 0.5-1.0 μg/kg/min, respectively, before and during surgery for hypotensive anesthesia. Anesthesia was induced by intravenous administration of 250 mg of thiopental, 6 mg of vecuronium bromide, and 0.3 mg of fentanyl. After the trachea was orally intubated with an 8.0 mm cuffed endotracheal tube, the lungs were ventilated with 60% nitrous oxide in oxygen at tidal volume of 500 ml with frequency of 10 cycles per minute. Before starting the surgery, the oral tracheal tube was replaced with a 9.0 mm spiral tracheal tube via a tracheostomy. During surgery and at 12 hours after the skin incision, peak inspiratory airway pressure was gradually increased to 30 CmH 2O from 15 cmH 2O, and SpO 2 was decreased to 97% from 100%, so we administered 100% O 2 and increased the sevoflurane concentration from 1.5% to 3%. After the patient's airway pressure was normalized, we lowered FIO 2 to 0.5. The surgery lasted 14.25 hours, and bleeding was 1,000 g. In the recovery room, his SpO 2 again dropped to 90%, despite the high flow of 10 l/min O 2 was administered. After receiving FIO 2 0.6 with 5 cmH 2O CPAP, his SpO 2 improved to 99%. Two days after surgery, under FIO 2 0.5 with 5 CmH 2O CPAP, his PaO 2 showed 99 mmHg. Eight days after surgery, his condition had improved enough for him to be weaned from the ventilator.

Original languageEnglish
Pages (from-to)86-89
Number of pages4
JournalJournal of Japanese Dental Society of Anesthesiology
Issue number1
Publication statusPublished - 2005


  • Hypoxia
  • Neck surgery
  • Postoperative respiratory complication
  • Risk factor


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