Letters to the Editor: Letters & Announcements
To the Editor
We report intraoperative severe hypotension, tachycardia, cerebral congestion, bleeding, and increased peak airway pressure caused by abdominal distension secondary to acutely distended bladder.
A 15-yr-old male patient underwent right craniectomy for excision of acoustic schwanomma. After induction of anesthesia, tracheal intubation, placement of arterial catheter in the dorsalis pedis, and central venous catheter, we placed a catheter in the bladder. His initial urine output was 150 mL. The patient was placed in the left lateral decubitus position, and surgery proceeded. After positioning, the tidal volume was 450 mL, peak airway pressure was 21 cm H2O, and end-tidal CO2 was 26 mm Hg. Over the first 2.5 h the patient received 1400 mL of crystalloid solution and 20 gm of mannitol. His urine output was 200 mL.
Over the subsequent 45 min his peak airway pressure increased to 29 cm H2O, and end-tidal CO2 increased to 38 mm Hg. The surgeon complained of increased oozing from the operative site. Chest auscultation revealed bilateral air entry without wheeze. We administered pancuronium and increased the tidal volume to 500 mL, further increasing the peak airway pressure to 32 cm H2O. Over the next 15 min, the patient’s arterial blood pressure decreased to a minimum of 56/26 mm Hg, with a dampened waveform, and his heart rate increased to 114 bpm. Fluid resuscitation did not improve his arterial blood pressure. Clinical examination revealed a distended bladder and tense abdomen. The urinary catheter had come out. After catheter replacement, 1600 mL of urine promptly drained, restoring normal hemodynamics and reducing surgical bleeding.
Failure to identify an inadvertently removed urinary catheter resulted in a distended bladder and increased abdominal pressure. Elevated abdominal pressure decreased lung compliance, accounting for the increased airway pressure. The high thoracic pressures may have decreased venous return, causing venous congestion in the head and increasing surgical bleeding. Alternatively, the high abdominal pressures may have partly occluded arterial flow to the legs, decreasing the arterial blood pressure measured in the dorsalis pedis, and accounting for the dampened waveform, while increasing the arterial blood pressure in the head and arms. Identification of a full bladder led to prompt resolution of the apparent hemodynamic instability.
Praveen K. Neema, MD
Shashi Rao, MD, DM
Sethuraman Manikandan, MD
Ramesh C. Rathod, MD
Sree Chitra Tirunal Institute for Medical Sciences and Technology
Trivandrum, Kerala, India