Acute massive collapse of the lungs: a case report.

ACUTE ~SSlVX COLL~S~. of the lungs is a rare clinical entity which may arise during or very soon after a surgical operation under all forms of anaesthesia? The history always contains details of increasing difficulty in inflating the patient's lungs, followed by rapid onset of cyanosis and death. Mechanical factors such as a kinked endotracheal tube or mucous plugs should be excluded prior to its diagnosis. H.H., 66, female, obese, was admitted to the medical ward with preliminary diagnosis of cholecystitis, myocardial insufficiency, and fight bronchopneumonia. The patient had an eight-year history of myocardial insufficiency and hypertension. She remained in the ward for two days and was treated with dignxin, guanethodine, spasmoverin, and tetracycline. Her temperature varied between 36 ~ and 38 ~ C. during this period. She bad a blood pressure of 180/105; haemoglobin, 13.6 gin.; total bilirubin, 2.1 rag.; serum protein, 6.1 gin.; K, 5.3, mEq.; Na, 149/mEq.; plasma bicarbonate, 20.9. mEq.; creaHnlne, 3.2 mg. per cent. An E.C.G. revealed left ventricular hypertrophy and myocardial insufficiency. Chest ibm showed right pulmonary estasis. On the third day her condition became worse. She complained of d i ~ s e tenderness on her upper abdomen. A diagnosis of gall-bladder peritonitis was made and the patient was sent to surgery. Pre-medication was 0.5 rag. atropine and 40 rag. pethedine intramuscularly one half hour before surgery. Blood pressure prior to anaesthesia was 160/100. Induction was commenced with 200 rag. of thiopentone followed by 50 rag. of succinylcholine. The luhgs were ventilated for a while with oxygen, and the patient was then intubated with a no. 9 cuffed tube. Anaesthesia was maintained with a nitrous-oxide--oxygen mixture in a ratio of 4:2 in a circle absorber system. Muscular relaxation was maintained by intermittent injections of 25 mg. of succinylcholine whenever it was required. The patient's blood pressure and pulse during the operation were satisfactory (B.P. between 180 and 9.00 mm.Hg and pulse 90-100). There was indeed perforation of the gall-bladder. The abdominal cavity was washed with saline solution. A rubber tube drain was placed in the foramen of Winslow and closure of the abdominal wall was commenced. It was at this point that no pulse was felt and no blood pressure was recorded. The patient became cyanotic and her pupils started to dilate. Increased resistance to inflation of the lungs was felt. External cardiac massage was immediately started and the lungs were insuttlated with oxygen. The patient was placed in Trendelenburg position. Intravenous adrenaline 2 ml. 1:1000, CaCI~ 10 per cent 4 ml., cortisone 100 rag., and cedilanid 0.4 rag. were given. Her heart fibrillated for a ~ of Anaesthesia, Ou]un Lii~.ninsairaala, Oulu, Finland.