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Letters to the Editor |
PO Box 9, Marrickville 1475, Sydney, New South Wales, Australia e-mail: stankoyovichevich@yahoo.com
Editor:
I read with great interest the article by Dr Barben and colleagues in the July 2002 issue of Radiology (1). The article is one of the most comprehensive and instructive in the challenging fields of respiratory medicine and interventional radiology and covers almost all aspects of treatment of cystic fibrosis and its complications.
There is one aspect that the authors failed to evaluate completely, however, with regard to the deaths of three patients (aged 7, 14, and 16 years) that resulted from induction of general anesthesia prior to bronchial artery embolization. According to available data, none of them were admitted as an emergency case.
Fatal complications of general anesthesia in patients with cystic fibrosis were described relatively recently, which would explain the authors’ unawareness at the time of early intervention.
The general safety guidelines were established at least 25 years ago in the fields of both interventional radiology and anesthesia, however, and were almost universally accepted (2). These are as follows: (a) Administration of general anesthesia is considered a high-risk procedure for all patients with compromised cardiorespiratory status and should accordingly be used only when indications are absolute, and even then with special precaution; (b) bronchial artery embolization is practically painless, making general anesthesia almost totally unnecessary; (c) older children, especially teenagers, are persuaded relatively easily and are reassured about the procedure, and complete cooperation is almost always obtained; and (d) even small or very anxious children are treated successfully with a combination of intravenous sedation and local anesthesia, making the procedure relatively easy to perform.
According to these guidelines and circumstances described in the article of Dr Barben and colleagues, the indications for general anesthesia in their three patients seem unclear to me.
The Latin term for major pulmonary hemorrhage is hemoptoe. The term hemoptysis is reserved for minor pulmonary hemorrhage only (blood streaks in sputum); this precise term somehow has been lost in the English literature. It would be useful to get it back.
REFERENCES
Department of Radiology, Royal Children’s Hospital, Parkville, Victoria 3052, Australia
As we mentioned in the discussion of our retrospective study (1), the death of the three patients following massive pulmonary hemorrhage during anesthetic induction for bronchial artery embolization has been reported in detail elsewhere (2). The authors believe that the unusual nature of forces associated with intermittent positive pressure ventilation are most likely to have been responsible for precipitating bleeding. High airway pressure alone is not an adequate explanation, since all children with cystic fibrosis have a long history of forceful cough. Pressure applied during cough is high (up to 300 cm H2O) but transient, lasting approximately 200 msec. In contrast, intermittent positive pressure ventilation (pressure less than 50 cm H2O that is applied for up to several seconds) causes airway distension, which is associated with an increase in airway wall tension. The prolonged increase in airway wall tension may have dislodged a clot that had been stable against stresses associated with coughing or may have precipitated bleeding from abnormal arteries that had not bled previously.
As a result of these events, the practice of administering anesthesia for bronchial artery embolization was changed from intermittent positive pressure ventilation to a combination of intravenous sedation and local anesthesia with spontaneous respiration whenever possible. Since 1997, when this approach was adopted, no further episodes of intraoperative bleeding have occurred. We completely agree that intermittent positive pressure ventilation should always be considered a high-risk procedure for patients with cystic fibrosis and should be avoided whenever possible.
REFERENCES
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