Anaesthesia, 1978, Volume 33, pages 617-619 C A S E REPORT
Ovarian cyst An unusual cause of respiratory arrest
A.R. H A R R I S O N A N D G . R . G . PURCELL
Without treatment ovarian tumours may enlarge to massive proportions. Spohn’ reported the removal of a tumour weighing nearly 150 kg (328 lb). This was the largest which was recorded amongst papers studied in a review of the literature by the authors-appropriately this was in Texas. This report concerns a case of respiratory arrest precipitated by an enormous ovarian cyst. Case report A 57-year-old woman, with a huge abdominal swelling, was admitted in extreme respiratory distress to the casualty department. There was gross pitting oedema of the whole body and engorged veins in the neck and over the anterior abdominal wall. A provisional diagnosis of massive ovarian cyst was made with cardiac failure secondary to compression of the lungs, mediastinum and inferior vena cava. Immediately after arrival the patient sustained respiratory arrest and she was intubated with an 8.0 mm cuffed ‘Portex’ endotracheal tube. Intermittent positive pressure ventilation with 100% oxygen was followed by a rapid return of spontaneous respiratory activity. Pancuronium 6 mg was given intravenously and ventilation was continued using a Manley Pulmovent delivering 50% nitrous oxide in oxygen. A minute volume of 6 litreslmin, with a tidal volume of 450 ml, was achieved at an inflation
pressure of 70 cm of water. Figure 1 shows the appearance of the patient shortly after intubation. A Teflon catheter was introduced percutaneously via the right external jugular vein into the right atrium and when attached to a central venous pressure manometer a value of 40 cm of water was measured from the sternal angle. The pulse rate was 100 per minute and the blood pressure was 110/60 mmHg. A paracentesis catheter was passed into the swelling and drainage of fluid was started at a maximum rate of 1 litre/h. After 3 litres had been removed the ventilator inflation pressure fell to 35 cmH20. The patient was transferred to the intensive care unit where intermittent positive pressure ventilation was continued employing a Cape ventilator with F102 of 0.35, tidal volume of 700 ml and a frequency of 12/ min. Arterial blood gas analysis showed pH 7.42, Po; 88 mmHg, Pco2 38 mmHg, HCOJ 28 mol/l and base excess + 3*5mmol/l. The cardiac failure was treated with diuretics and the central venous pressure fell to 5 c m H 2 0 after 48 h. After 4 days a total of 44 litres of fluid had been drained from the abdomen, the catheter was then removed and the patient was extubated the following day. However on the sixth day accumulation of fluid began once more and tracheal intubation and ventilation were again necessary.
Dr A.R. Harrison FFARCS, Registrar, and Dr G.R.G. Purcell FFARCS, Senior Registrar, Department of Anaesthetics, Southampton University Hospitals. Dr Harrison is now Senior Registrar in Anaesthetics, St Thomas’s Hospital, London. 0003-2409/78/0700-0617$02.00
0 1978 Blackwell Scientific Publications
617
618
A.R. Harrison and G.R.G.PurceN
Fig. 1. The patient shortly after admission.
On the ninth day, at laparotomy, a huge ovarian cyst was excised and a tracheostomy was performed. Postoperatively the patient made a good recovery. Spontaneous respiration was easily established on the following day and the tracheostomy tube was removed 4 days later. The patient left hospital for convalescence 21 days after admission.
Discussion Deleterious effects on lung function have been described in cases of large intra-abdominal tumours,2 abdominal binding3 and severe o b e ~ i t y .Elevation ~ and splinting of the diaphragm may diminish functional residual capacity, vital capacity and total lung capacity. Reduction of functional residual capacity below closing volume leads to regions of lung in which there is trapping of gas behind closed airways. Continued perfusion of these regions leads to increased shunting and consequent arterial h y p o ~ a e m i a .It~ ~must ~ be unusual for this
situation to progress to the point of imminent respiratory arrest before medical advice is sought. The problems associated with the treatment of large intra-abdominal tumours are well described by Hoile.2 In particular, sudden removal of the large mass may cause serious alterations in venous return. Splanchnic vasodilatation and venous pooling may lead to decreased venous return. On the other hand an increase in venous return may result from decompression of the inferior vena cava. It was felt that this patient, in gross cardiac failure, was unlikely to tolerate either of these changes. Drainage of the cyst fluid was therefore undertaken slowly and cardiac failure was treated before an operation was considered. At operation it was noted that the diaphragm, which had been severely stretched, was extremely lax. Postoperative respiratory problems were anticipated and for this reason a tracheostomy was performed. I n fact, the patient was easily weaned off the ventilator the following day and made an uneventful recovery.
Ovarian cyst
619
Summary
References
Respiratory arrest in a patient with a huge ovarian cyst is described. The successful resuscitation and subsequent management of the case are outlined.
1. SPOHN,A.E. (1905-1906) Multicystic ovarian tumor weighing 328 pounds. Texas Journal of Medicine, 1, 273. 2. HOILE,R.W. (1976) Hazards in the management of
Key words SURGERY; gynaecological, massive ovarian cyst. VENTILATION; failure.
Acknowledgments The authors would like to thank Mr J.D. Jenkins, Consultant Surgeon, and Dr A.K. Dewar, Consultant Anaesthetist, for permission to publish this case.
large intra-abdominal tumours. Annals of the Royal College of Surgeons of England, 58, 393. 3. CARO, C.G., BUTLER,J. & DUBOIS(1960) Some effects of restriction of chest cage expansion on pulmonary function in man: an experimental study. Journal of Clinical Investigation, 39, 573. 4. RORVIK,S. & Bo, G. (1976) Lung volumes and arterial blood gases in obesity. Scandinavian Journal of Respiratory Diseases, Supplement 95, 60. 5 . DON,H.F., CRAIG,D.B., WAHBA,W.M. & COUTURE, J.G. (1971) The measurement of gas trapped in the lungs at functional residual capacity and the effects of posture. Anesthesiology, 35, 582. 6. MARSHALL, B.E.& WYCHE,M.Q., JR (1972) Hypoxemia during and after anesthesia. Anesthesiology, 37, 178.
Ovarian cyst An unusual cause of respiratory arrest
A.R. H A R R I S O N A N D G . R . G . PURCELL
Without treatment ovarian tumours may enlarge to massive proportions. Spohn’ reported the removal of a tumour weighing nearly 150 kg (328 lb). This was the largest which was recorded amongst papers studied in a review of the literature by the authors-appropriately this was in Texas. This report concerns a case of respiratory arrest precipitated by an enormous ovarian cyst. Case report A 57-year-old woman, with a huge abdominal swelling, was admitted in extreme respiratory distress to the casualty department. There was gross pitting oedema of the whole body and engorged veins in the neck and over the anterior abdominal wall. A provisional diagnosis of massive ovarian cyst was made with cardiac failure secondary to compression of the lungs, mediastinum and inferior vena cava. Immediately after arrival the patient sustained respiratory arrest and she was intubated with an 8.0 mm cuffed ‘Portex’ endotracheal tube. Intermittent positive pressure ventilation with 100% oxygen was followed by a rapid return of spontaneous respiratory activity. Pancuronium 6 mg was given intravenously and ventilation was continued using a Manley Pulmovent delivering 50% nitrous oxide in oxygen. A minute volume of 6 litreslmin, with a tidal volume of 450 ml, was achieved at an inflation
pressure of 70 cm of water. Figure 1 shows the appearance of the patient shortly after intubation. A Teflon catheter was introduced percutaneously via the right external jugular vein into the right atrium and when attached to a central venous pressure manometer a value of 40 cm of water was measured from the sternal angle. The pulse rate was 100 per minute and the blood pressure was 110/60 mmHg. A paracentesis catheter was passed into the swelling and drainage of fluid was started at a maximum rate of 1 litre/h. After 3 litres had been removed the ventilator inflation pressure fell to 35 cmH20. The patient was transferred to the intensive care unit where intermittent positive pressure ventilation was continued employing a Cape ventilator with F102 of 0.35, tidal volume of 700 ml and a frequency of 12/ min. Arterial blood gas analysis showed pH 7.42, Po; 88 mmHg, Pco2 38 mmHg, HCOJ 28 mol/l and base excess + 3*5mmol/l. The cardiac failure was treated with diuretics and the central venous pressure fell to 5 c m H 2 0 after 48 h. After 4 days a total of 44 litres of fluid had been drained from the abdomen, the catheter was then removed and the patient was extubated the following day. However on the sixth day accumulation of fluid began once more and tracheal intubation and ventilation were again necessary.
Dr A.R. Harrison FFARCS, Registrar, and Dr G.R.G. Purcell FFARCS, Senior Registrar, Department of Anaesthetics, Southampton University Hospitals. Dr Harrison is now Senior Registrar in Anaesthetics, St Thomas’s Hospital, London. 0003-2409/78/0700-0617$02.00
0 1978 Blackwell Scientific Publications
617
618
A.R. Harrison and G.R.G.PurceN
Fig. 1. The patient shortly after admission.
On the ninth day, at laparotomy, a huge ovarian cyst was excised and a tracheostomy was performed. Postoperatively the patient made a good recovery. Spontaneous respiration was easily established on the following day and the tracheostomy tube was removed 4 days later. The patient left hospital for convalescence 21 days after admission.
Discussion Deleterious effects on lung function have been described in cases of large intra-abdominal tumours,2 abdominal binding3 and severe o b e ~ i t y .Elevation ~ and splinting of the diaphragm may diminish functional residual capacity, vital capacity and total lung capacity. Reduction of functional residual capacity below closing volume leads to regions of lung in which there is trapping of gas behind closed airways. Continued perfusion of these regions leads to increased shunting and consequent arterial h y p o ~ a e m i a .It~ ~must ~ be unusual for this
situation to progress to the point of imminent respiratory arrest before medical advice is sought. The problems associated with the treatment of large intra-abdominal tumours are well described by Hoile.2 In particular, sudden removal of the large mass may cause serious alterations in venous return. Splanchnic vasodilatation and venous pooling may lead to decreased venous return. On the other hand an increase in venous return may result from decompression of the inferior vena cava. It was felt that this patient, in gross cardiac failure, was unlikely to tolerate either of these changes. Drainage of the cyst fluid was therefore undertaken slowly and cardiac failure was treated before an operation was considered. At operation it was noted that the diaphragm, which had been severely stretched, was extremely lax. Postoperative respiratory problems were anticipated and for this reason a tracheostomy was performed. I n fact, the patient was easily weaned off the ventilator the following day and made an uneventful recovery.
Ovarian cyst
619
Summary
References
Respiratory arrest in a patient with a huge ovarian cyst is described. The successful resuscitation and subsequent management of the case are outlined.
1. SPOHN,A.E. (1905-1906) Multicystic ovarian tumor weighing 328 pounds. Texas Journal of Medicine, 1, 273. 2. HOILE,R.W. (1976) Hazards in the management of
Key words SURGERY; gynaecological, massive ovarian cyst. VENTILATION; failure.
Acknowledgments The authors would like to thank Mr J.D. Jenkins, Consultant Surgeon, and Dr A.K. Dewar, Consultant Anaesthetist, for permission to publish this case.
large intra-abdominal tumours. Annals of the Royal College of Surgeons of England, 58, 393. 3. CARO, C.G., BUTLER,J. & DUBOIS(1960) Some effects of restriction of chest cage expansion on pulmonary function in man: an experimental study. Journal of Clinical Investigation, 39, 573. 4. RORVIK,S. & Bo, G. (1976) Lung volumes and arterial blood gases in obesity. Scandinavian Journal of Respiratory Diseases, Supplement 95, 60. 5 . DON,H.F., CRAIG,D.B., WAHBA,W.M. & COUTURE, J.G. (1971) The measurement of gas trapped in the lungs at functional residual capacity and the effects of posture. Anesthesiology, 35, 582. 6. MARSHALL, B.E.& WYCHE,M.Q., JR (1972) Hypoxemia during and after anesthesia. Anesthesiology, 37, 178.
