LAUSR

A 35-year-old male of American Society of Anesthesiologists (ASA) grade 1 and weighing 60 kg was posted for laparoscopic cholecystectomy. Preanaesthetic check-up was unremarkable. On the day of surgery, he had a blood pressure (BP) of 164/90 mm of Hg and heart rate (HR) of 100/minute. Intravenous (IV) midazolam 1 mg followed by fentanyl bolus of 100 μg was injected over a period of 30 seconds. He was preoxygenated for 3 minutes, after which an increase in serial two BP readings of 164/110 and 162/112 mmHg and HR readings of 106/min and 110/min respectively (2 minutes apart) was observed. This was followed by induction with intravenous (IV) propofol 120 mg. Bag and mask ventilation was unsatisfactory with no visible chest rise despite adequate head tilt and jaw thrust. An oropharyngeal airway was negotiated with difficulty. Subsequently, injection succinylcholine 120 mg was administered. Laryngoscopy revealed a significantly narrowed glottic opening (Cormack Lehane grade 2b) and intubation was successful at the first attempt. Thereafter, auscultation revealed a completely silent chest with no capnogram trace. The patient was ventilated with 100% oxygen. After deepening the plane with sevoflurane, endotracheal tube position was reconfirmed and endotracheal suctioning revealed free catheter passage. IV hydrocortisone 100 mg and dexamethasone 8 mg were administered. Ventilation with volume control mode was unsuccessful with an unusually high airway pressure (35 cmH20) and non-delivery of tidal volume, that was overcome by switching to pressure regulated volume mode. Intraoperative arterial blood gas (ABG) analysis showed pH of 7.28. The duration of inadequate ventilation was around 5 minutes. Intraoperatively, the patient continued to have tachycardia, hypertension and high airway pressure which were relieved gradually intraoperatively. Post-induction ABG analysis revealed respiratory acidosis[pH 7.18, partial pressure of carbon dioxide (pCO2) 90 mm of Hg at a fractional inspired concentration of oxygen (FiO2) of 1 and a positive end-expiratory pressure (PEEP) of 8 cm of water.] Dexmedetomidine infusion was started, titrated and stopped prior to reversal. The surgery lasted for about 1.5 hours. Extubation and the postoperative period were uneventful. ABGs analysed before and 15 minutes post-extubation was within normal limits.