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CASE REPORT
Year : 2022  |  Volume : 25  |  Issue : 6  |  Page : 967-970

A case of diffuse alveolar hemorrhage after orthognathic surgery: Case report with the literature review'


Department of Oral and Maxillofacial Surgery, Erciyes University Faculty of Dentistry, Melikgazi, Kayseri, Turkey

Date of Submission06-Oct-2021
Date of Acceptance31-Jan-2022
Date of Web Publication16-Jun-2022

Correspondence Address:
Dr. S O Yasli
Department of Oral and Maxillofacial Surgery, Erciyes University Faculty of Dentistry, Melikgazi, Kayseri
Turkey
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njcp.njcp_1869_21

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   Abstract 


Diffuse alveolar hemorrhage (DAH) disease is a rare but acutely developing condition that may occur after general anesthesia, if not diagnosed and treated on time, could be life-threatening. Orthognathic surgeries, frequently performed for functional and esthetic correction, are generally composed of a young population in their twenties with no other disease. The aim of presenting this case report was to describe the etiology, diagnosis, and treatment of DAH to emphasize the importance of timely diagnosis.

Keywords: Diffuse alveolar hemorrhage, orthognathic surgery, postoperative complication, sevoflurane


How to cite this article:
Yasli S O, Dogruel F, Demirbas A E, Canpolat D G. A case of diffuse alveolar hemorrhage after orthognathic surgery: Case report with the literature review'. Niger J Clin Pract 2022;25:967-70

How to cite this URL:
Yasli S O, Dogruel F, Demirbas A E, Canpolat D G. A case of diffuse alveolar hemorrhage after orthognathic surgery: Case report with the literature review'. Niger J Clin Pract [serial online] 2022 [cited 2022 Sep 29];25:967-70. Available from: https://www.njcponline.com/text.asp?2022/25/6/967/347615




   Introduction Top


Diffuse alveolar hemorrhage (DAH) is a clinicopathological condition defined as erythrocyte passage from the alveolar capillaries into the alveoli.[1] It can be seen because of events that cause damage to the alveolar microcirculation. It usually accompanies a group of immune-derived systemic vasculitis or connective tissue diseases.[2] However, in the absence of clinical, serological, or histological findings indicating concomitant systemic disease, it can also be seen due to isolated pulmonary capillarities (IPC).[3] The classical triad in the diagnosis of DAH is anemia, hemoptysis, and bilateral alveolar infiltrates that appear on chest radiography. However, hemoptysis may not be seen in one-third of the cases.[1]

We present a case of “Isolated Pulmonary Capillaritis (IPC)” presenting with DAH that occurred during the recovery period immediately after general anesthesia, not associated with anti-neutrophil cytoplasmic autoantibody (ANCA) and without systemic involvement.


   Case Report Top


The institutional review board approved this case of Erciyes University. The patient provided informed consent to publish his clinical and imaging data.

A 22-year-old male patient applied to the maxillofacial surgery clinic of the Erciyes University Faculty of Dentistry to undergo double jaw surgery due to a dentofacial anomaly.

The patient's preoperative examination was unremarkable, with the American Society of Anesthesiologists (ASA) physical status of I. In the operating room, the standard monitoring applied to the patient includes pulse oximetry, electrocardiography, and noninvasive blood pressure monitoring.

Induction of anesthesia was initiated in the standard manner with 2 mg/kg Propofol (Propofol 1% Fresenius, Fresenius Kabi Deutschland, Bad Homburg, Germany), 0.5 mg/kg rocuronium (Emerson; GlaxoSmithKline, United Kingdom), and 1 mcg/kg fentanyl (Fentanyl 0.05 mg/mL, 10 mL ampoule, Johnson& Johnson, Belgium). About 2.5% Sevoflurane (Sevorane®; Abbott, Chicago, IL, USA) and 50% oxygen–air mixture were used for the maintenance of the patient, whose nasotracheal intubation was performed without any problem. After that, adequate tidal volume was obtained with spontaneous breathing, and sufficient muscle recovery was reached, tracheal extubation was carried out. No complications associated with surgery or anesthesia were encountered during surgery, like bleeding, hypotension, or desaturation event. Before the transfer of the patient to the recovery room, the patient's oxygen saturation dropped to 75% when oxygen support of the patient was discontinued. A rapid physical examination of the patient was performed after stopping the oxygen support, and it was noticed that the patient was conscious and oriented-cooperative. Both lungs had equal participation during respiration, but examination of the chest revealed bilateral coarse inspiratory crepitation.

At this point, we continued to observe the patient by providing oxygen support. After nasal oxygen support connected to the oxygen tube was provided for the patient, he was transferred to the recovery unit with oxygen support. Respiratory rate was 23/min, pulse was 116 bpm, blood pressure was 120/70 mm/Hg, the temperature was 36.8°C, and peripheral oxygen saturation was 75–85% without nasal or mask oxygen support. Arterial blood gases were checked to aid the diagnosis. Posteroanterior (PA) radiography of the chest, complete blood count (CBC), and blood biochemistry were also requested. Arterial blood gas tensions measured while the patient breathes ambient air were as follows: pH was 7.45, PaCO2 was 25 mmHg, PaO2 was 54 mm Hg, and O2 saturation was 90%. In the postoperative period, bilateral diffuse patchy infiltrates were noted on PA lung radiography although preoperative PA lung radiography was unremarkable [Figure 1]. Except for the serum hemoglobin value, the blood biochemistry and CBC were unremarkable. It was noticed that the hemoglobin value of the patient, whose intraoperative bleeding was recorded as 200 CC, was decreased by approximately 2 g/dL (preoperative Hgb: 15.1, postoperative Hgb: 12.8).
Figure 1: PA lung radiograph showing bilateral diffuse patchy infiltrates

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The patient was consulted by the chest physician. The chest physician requested and evaluated the other necessary tests, such as pulmonary computed tomography (CT). The CT result was interpreted as having ground-glass opacities and consolidated areas in all lung lobes, denser in the lower posterior lobes [Figure 2]. Since the surgery was performed intra-orally, deep aspirations were always bloody. Because of the urgent need for diagnosis, bronchi were accepted as one of the sources of bloody aspirates. The patient was diagnosed as having DAH following the clinical and radiological findings (characteristic diffuse ground-glass opacity and infiltrations, anemia [serum hemoglobin level dropped by approximately 2 mg/dL], bloody sputum during endotracheal suction and, hypoxemic respiratory failure [PaO2/FiO2 value indicates the acute respiratory failure.[4] For present case it was 54/0.21 = 257 which refers to moderate hypoxemia]). The patient was hospitalized at the Department of Chest Disease.
Figure 2: CT Image of Diffuse Alveolar Hemorrhage

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The patient was followed up with oxygen support and 1000 mg/day IV methylprednisolone (Prednol, Mustafa Nezcat Drug Co, Istanbul, Turkey), and diuretic and antibiotherapy treatment was started. Serological markers were requested to exclude autoimmune and systemic diseases. Results are given in [Table 1].
Table 1: Requested serological markers and results of them

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During follow-ups, the patient's oxygen saturation improved while the patient breathed ambient air. On the third day of hospitalization, oxygen saturation was observed to be at 95% in room air, and posterior anterior (PA) lung radiograph was normal [Figure 3]. The patient was discharged from the chest diseases service on third day, and the patient was told to gradually stop methylprednisolone in 7 days.
Figure 3: PA lung Radiograph at Discharge

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   Discussion Top


DAH is a condition that results in acute respiratory failure syndrome (ARDS) and can be fatal if a rapid diagnosis is not made and the treatment is not initiated immediately.[5] In-hospital mortality has been reported to be 20–100%.[3] The most common underlying cause of DAH is pulmonary vasculitis of small vessels, also known as pulmonary capillaritis. In the present case, the patient was considered IPC because no signs of systemic disease were found in the advanced examinations performed, and the serological tests were negative.

In the literature, the cause of reported postoperative DAH cases, in which immunological diseases were excluded, can be listed as follows: inhalation of anesthetic gas (Sevoflurane), use of an anticoagulant during neurosurgery, chronic alveolar damage caused by chronic obstructive sleep apnea.[6],[7],[8]

Supplemental O2 is routinely administered to patients who receive anesthesia to avoid or treat hypoxemia through the postoperative period in the post-anesthesia care unit.[9] So, hypoxemia is common in patients in the recovery period from general anesthesia but usually resolves with oxygen support. In the present case, the authors encountered and suspected the problem of low SpO2 levels, which could not rise sufficiently despite oxygen support in the postoperative period.

In the present case, the cause of DAH was thought to be IPC caused by sevoflurane inhalation, according to the conclusion reached by excluding the other possible diagnoses.

Sevoflurane is metabolized directly into two types of toxic metabolite products by alkaline carbon dioxide absorbers in the circuits of anesthesia machines. The primary metabolite is fluoromethyl-2,2-difluoro-1-(trifluoromethyl) vinyl ether, designated Compound A. It is known in the literature that Compound A causes renal toxicity.[10] Volatile gases are oil-soluble and strengthen the arachidonic cascade in the cell membrane.[6] As a result, exposure can cause alveolar permeability, increased oxidative stress, and increased inflammatory response. So, Sevoflurane may activate a similar pathway in the appropriate setting.

In conclusion, if the peripheral oxygen value does not reach the desired level, despite mask oxygen support during the postoperative recovery period, DAH should be among the diagnoses that should be considered. It should be kept in mind that delaying further examination and treatment could cause the process to progress to a syndrome with high mortality, such as ARDS.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Lara AR, Schwarz MI. Diffuse alveolar hemorrhage. Chest 2010;137:1164-71.  Back to cited text no. 1
    
2.
Al-Adhoubi NK, Bystrom J. Systemic lupus erythematosus and diffuse alveolar hemorrhage, etiology and novel treatment strategies. Lupus 2020;29:355-63.  Back to cited text no. 2
    
3.
Alexandre AT, Vale A, Gomes T. Diffuse alveolar hemorrhage: How relevant is etiology? Sarcoidosis Vasc Diffuse Lung Dis 2019;36:47-52.  Back to cited text no. 3
    
4.
Gallagher H, Kwan JT, Jayne DR. Pulmonary renal syndrome: A 4-year, single-center experience. Am J Kidney Dis 2002;39:42-7.  Back to cited text no. 4
    
5.
Raptis A, Mavroudis D, Suffredini A, Molldrem J, Rhee FV, Childs R, et al. High-dose corticosteroid therapy for diffuse alveolar hemorrhage in allogeneic bone marrow stem cell transplant recipients. Bone Marrow Transplant 1999;24:879-83.  Back to cited text no. 5
    
6.
Austin A, Modi A, Judson MA, Chopra A. Sevoflurane ınduced diffuse alveolar hemorrhage in a young patient. Respir Med Case Rep 2017;20:14-5.  Back to cited text no. 6
    
7.
Choe YS, Kim NY, Lee AR. Diffuse alveolar hemorrhage in patients undergoing neurointervention: A case report. Anesth Pain Med 2016;6:e33979.  Back to cited text no. 7
    
8.
Kim JP, Park JJ, Kim NJ, Woo SH. A case of diffuse alveolar hemorrhage after tonsillectomy -A case report. Korean J Anesthesiol 2012;63:165-8.  Back to cited text no. 8
    
9.
Kluger MT, Bullock MF. Recovery room incidents: A review of 419 reports from the Anaesthetic Incident Monitoring Study (AIMS). Anaesthesia 2002;57:1060-6.  Back to cited text no. 9
    
10.
Behne M, Wilke HJ, Harder S. Clinical pharmacokinetics of sevoflurane. Clin Pharmacokinet 1999;36:13-26.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1]



 

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