Case presentation
A 65-year-old man (175.0 cm, 65.0 kg) with a 23-year history of PD was scheduled to undergo C3-C7 cervical laminectomy with C3/C4 posterior fixation for cervical spondylosis. The patient was taking antiparkinson drugs, including levodopa-carbidopa taken four times a day. Symptoms of PD were well-controlled with drugs so that he was able to live independently. He was admitted to the hospital the day before surgery. The patient took the last medication the night before surgery, 13 hours before anesthesia. Considering the well-controlled PD status, oral anitparkinson drugs on the morning of surgery were neither administrated nor replaced by intravenous levodopa.
General anesthesia was induced and maintained with continuous infusions of propofol and remifentanil. Rocuronium (40 mg) was given to facilitate tracheal intubation. After the patient was placed in the prone position, neuromuscular relaxation was antagonized with sugammadex (150 mg) for monitoring of motor-evoked potentials, which remained unsuppressed throughout surgery. Arterial oxygen saturation (SpO2) was maintained between 97% and 99%, and arterial oxygen tension (PaO2) was 201 mmHg with inspired oxygen fraction (FIO2) of 0.5. Fentanyl (150 μg) and acetaminophen (1,000 mg) were intravenously administrated for immediate postoperative analgesia. Durations of surgery and anesthesia were 161 and 254 minutes, respectively. Intraoperative fluid infusion, blood loss, and urine output were 1,410 mL, 60 mL, and 400 mL, respectively.
After emergence from anesthesia, a sufficient tidal volume and respiratory rate were confirmed. The patient could take a deep breath and move extremities voluntarily, as requested by anesthesiologists. Immediately after tracheal extubation, however, the patient presented with labored breathing. Inspiratory stridor was heard. Systolic blood pressure increased to 200 mmHg. SpO2 dropped to 78%. PaO2 was 61 mmHg during administration of oxygen at 8L/min via face mask. The patient’s UAO was immediately treated with a jaw thrust maneuver and tightly fitted face mask. An immediate chest X-ray showed diffuse bilateral pulmonary consolidation without an increased cardiothoracic ratio, consistent with negative pressure pulmonary edema (NPPE) (Figure 1). Thus, 10-cm H2O positive end-expiratory pressure (PEEP) was applied to the spontaneously breathing patient using an anesthesia circuit. PaO2increased to 105 mmHg.
The patient was transferred to the intensive care unit. High-flow nasal cannula therapy (HFNC) was initiated with FIO2 of 0.6 and a flow rate of 50 L/min. NPPE improved by the morning of postoperative day (POD) 1; PaO2 increased to 204 mmHg with FiO20.6. Administration of antiparkinson drugs was resumed. On POD 2, the patient was weaned from HFNC, and returned to the ward without any oxygen supply.