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Table of Contents
LETTER TO THE EDITOR
Year : 2011  |  Volume : 27  |  Issue : 2  |  Page : 288-289

Intraoperative propofol-induced desaturation in lateral position during posterior fossa surgery


Department of Anaesthesiology, All India Institute of Medical Sciences, New Delhi, India

Date of Web Publication3-Jun-2011

Correspondence Address:
Dalim Kumar Baidya
Department of Anaesthesiology, 8/67, AIIMS Campus, All India Institute of Medical Sciences, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0970-9185.81852

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How to cite this article:
Baidya DK, Sherfudeen KM, Chaturvedi A. Intraoperative propofol-induced desaturation in lateral position during posterior fossa surgery. J Anaesthesiol Clin Pharmacol 2011;27:288-9

How to cite this URL:
Baidya DK, Sherfudeen KM, Chaturvedi A. Intraoperative propofol-induced desaturation in lateral position during posterior fossa surgery. J Anaesthesiol Clin Pharmacol [serial online] 2011 [cited 2019 Oct 19];27:288-9. Available from: http://www.joacp.org/text.asp?2011/27/2/288/81852

Sir,

A 35-year-old man, weighing 70 kg, was posted for left retromastoid suboccipital craniotomy and excision of left cerebello-pontine angle tumor. He had pulmonary tuberculosis 20 years ago and right upper lung-zone fibrosis on chest X-ray. Rest of the examination and investigations were unremarkable.

Anesthesia was induced with intravenous fentanyl 150 μg, propofol 120 mg, and rocuronium 70 mg. Trachea was intubated with 8.5 mm orotracheal flexometallic tube. Right subclavian central venous and right radial artery catheters were placed. Anesthesia was maintained with O 2 -air-isoflurane with intermittent vecuronium and fentanyl. The patient was positioned right lateral with right arm hanging beyond the cephalic edge of the table. Intraoperatively, brain relaxation was inadequate despite mannitol 1 g/kg. So, propofol was started at 10 mg/kg/h after 50 mg bolus and isoflurane was switched off. Within 2 min, oxygen saturation (SpO 2 ) decreased to 76%. Heart rate increased to 90/min from 75/min and blood pressure decreased to 84/50 from 110/70 mmHg. Airway pressure and capnography were normal. Lung fields were clear on auscultation and bilateral air-entry was equal. EtCO 2 decreased slightly from 33 to 31 mmHg. Sample for arterial blood gas (ABG) was sent immediately; 100% O 2 was started and ephedrine 6 mg was injected intravenously. Propofol infusion was stopped. SpO 2 increased to 90% over 5 min and reached 98% after 15 min. FiO 2 was decreased to 0.5 and another sample for ABG sent. Serial ABG reports are shown as [Table 1]. Blood pressure increased to 110/65 mmHg over 10 min. Propofol infusion was restarted at 6 mg/kg/h. Brain relaxation was adequate subsequently and surgery was completed uneventfully. Trachea was extubated and the patient was shifted to ICU for overnight observation.
Table 1: Arterial blood gases at points of time

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Propofol bolus can cause hypotension, but intraoperative desaturation is rare. The possible causes of desaturation can be an increase in ventilation-perfusion mismatch, pulmonary embolism or allergic reaction. An episode of pulmonary embolism would have caused significant fall in EtCO 2 and persistent desaturation even after normalization of blood pressure. An allergic reaction is unlikely to get relieved without any anti-inflammatory drugs.

In anesthetized-paralyzed patient, change of position from supine to lateral has been shown to increase V/Q mismatch (pulmonary shunt increases from 5% in supine position to 10%-15% in lateral position), decrease in PaO 2 and increase in areas of atelectasis in the dependent lung in CT scan. [1],[2] Furthermore, regional V/Q distribution becomes significantly less uniform as fractional blood flow through the atelectatic areas increase with anesthesia-paralysis in the right lateral position. [3],[4] This increase in V/Q mismatch is reflected as an increase in P(A − a)O 2 gradient.

The patient had right upper lung-zone fibrosis and therefore V/Q mismatch, which was increased under anesthesia in the right lateral position. During the phase of propofol-induced acute hypotension, gravitational force may have significantly decreased the perfusion of the nondependent lung, and presence of residual isoflurane (0.8%) in the circuit reduced the pulmonary vascular tone of the dependent lung and reduced pulmonary blood flow of the nondependent lung. [5] Both the factors further increased V/Q mismatch, widening the (A − a) gradient, which lead to desaturation.

In conclusion, intraoperative propofol bolus can lead to significant desaturation in lateral position, particularly if it is associated with hypotension and pathological dependent lung.

 
   References Top

1.Klingstedt C, Hedenstierna G, Baehrendtz S, Lundqvist H, Strandberg A, Tokics L, et al. Ventilation-perfusion relationships and atelectasis formation in the supine and lateral positions during conventional mechanical and differential ventilation. Acta Anaesthesiol Scand 1990;34:421-9.   Back to cited text no. 1
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2.Landmark SJ, Knopp TJ, Rehder K, Sessler AD. Regional pulmonary perfusion and V/Q in awake and anesthetized-paralyzed man. J Appl Physiol 1977;43:993-1000.   Back to cited text no. 2
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3.Rehder K, Knopp TJ, Sessler AD, Didier EP. Ventilation-perfusion relationship in young healthy awake and anesthetized-paralyzed man. J Appl Physiol 1979;47:745-53.  Back to cited text no. 3
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4.Bindslev L, Hedenstierna G, Santesson J, Gottlieb I, Carvallhas A. Ventilation-perfusion distribution during inhalation anaesthesia. Acta Anaesthesiol Scand 1981;25:360-71.  Back to cited text no. 4
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5.Ewalenko P, Stefanidis C, Holoye A, Brimioulle S, Naeije R. Pulmonary vascular impedance vs. resistance in hypoxic and hyperoxic dogs: Effects of propofol and isoflurane. J Appl Physiol 1993;74:2188-93.  Back to cited text no. 5
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