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A case of congenital lung cysts disease is presented.

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- Sevoflurane Failed Induction of Anaesthesia in Child Affected By Congenital Cystic Adenomatoid Malformation


We present an interesting case of congenital lung cysts disease anesthetized by sevoflurane inhalation [1] demonstrated unsuitable condition for intubation. This may be reflection of defective physiological transfer of inhalational agents. The situation remedied by supplement of ketamine and rocuronium for intubation then inhalation continued with sevoflurane

Case Report

A 27 weeks gravid premature girl, weighing 1000 g at birth, delivered to G7 P6+1 mother who had eclampsia at 72 weeks of gestation.

At the age of 4 weeks the girl was intubated and ventilated for 26 days due to respiratory impairment.

Later she was diagnosed as a case of:

(1) Retinopathy of prematurity

(2)  Congenital bronchopulmonary dysplasia

No other medical diseases were documented.

She was referred from peripheral hospital to ophthalmic unit at King Fahad Medical City for laser surgery to control congenital retinopathy.

The girl was admitted to the NICU, and investigated and found to have right lung cyst. The treating physician asked an anesthesia consultation for laser surgery.

On examination:

The girl was kept in an incubator. She was breathing spontaneously, active and on oxygen supplements 4 L per minute via mask. Auscultation of the chest did not elicit abnormality. Vital signs; HR: 170 b per minutem. Chest was quite with breathing sounds. Blood pressure: 85/40 mmHg.  RR-35 b/m. She was on oral feeding.

Laboratory Investigations showing: urea: 1.4 mmol -1. creatinine 19.0 µmol.l -1 . K: 5.5 mEq.l-1  Na :141 mEq.l-1Hb:11 g.dl-1  platelets:497 x10.e9.l-1 Coagulation profile pt:12.4, Aptt:40.1

Pulmonologist who cared for the chest condition advised that the lung cysts are small in size. A pediatric surgical consultation for management of the lung cyst obtained, and advised that there is no need for urgent surgery, but advised that if pneumothorax develops during laser surgery then immediate intervention should take place.

On 18-8-2007 Anesthesia took place.

Inhalational induction using sevoflurane, Anesthesiologist took long induction before laryngoscopy and tried intubation but found the condition was not proper for intubation, the girl was “fighting,” so since she was on sevoflurane inhalation supplemental ketamine was given intravenously in dose 0.5 mg kg-1.  Atropine - 0.1mg given as well then Recuronium- 3 mg was injected, so the trachea was intubated successfully. The respiration resumed with the tube in place.

Anesthesia maintained on sevoflurane 2% in Air:Oxygen mixture.

Respiration was spontaneous with occasional ventilatory manual support.

Finally at the one hour procedure, the girl was extubated after she recovered completely and was sent back to NICU on 4L O2 with SpO2 100%. Later on, she was discharged to primary hospital on 28.8.2007 in good condition.


Congenital Cystic Adenomatoid Malformation (CCAM) was reviewed recently [1]. It is a rare congenital malformation of the lung representing 25% of congenital lung malformations and 95% of congenital lung lesions [2, 3]. This lesion occurs more often in males (1.8:1), and is primarily unilateral, but may occur bilaterally. [4].

CCAM with severe respiratory dysfunction from birth was reported and the anesthetic coerce was dependent on sevoflurane inhalation and spontaneous respiration. It was 5-day-old-boy with CCAM underwent removal of a large cyst which was present at lower lobe of right lung. Anesthesia was induced slowly and maintained with oxygen and sevoflurane. Severe airway obstruction occurred transiently by the secretion from the lung cyst. Thereafter, the surgery was completed safely and his postoperative course was uneventful [5]. 

A recent report describing a left pneumonectomy performed on a six week-old female infant suffering from respiratory distress related to cystic changes affecting the entire left lung. Anesthesia was induced with sevoflurane in oxygen and spontaneous ventilation was maintained until intubation of the right main bronchus was secured. The postoperative course was uneventful. The pathological diagnosis was pulmonary interstitial emphysema [6, 7]. In the case we are presenting; inhalation of sevoflurane given for long period, the patient did not relax enough for intubation though high concentration 6% sevoflurane and three minutes has passed. Ketamine supplement and recuronium were used to secure the airway. We conclude that induction of these cases for surgery is adopting inhalational method to prevent cysts from distention if IPPV is used. But the lung pathology may elongate the inhalational induction for manipulation of the airway. Alternatively intravenous induction with anesthetics and muscle relaxant would control the airway. Also gentile ventilation would provide oxygenation and elimination of carbon dioxide.

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