LETTER TO EDITOR
Year : 2015 | Volume
| Issue : 3 | Page : 335-336
Resistant hypercarbia in a patient with interstitial lung disease undergoing resection for right parietoccipital meningioma
Zulfiqar Ali1, Talib Khan2, Sumaya Syed2, Bashir Ahmad Dar1, Syed Amir Zahoor2
1 Department of Anesthesiology, Division of Neuroanesthesiology, Sher-i-Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India
2 Department of Anesthesiology, Sher-i-Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India
Dr. Zulfiqar Ali
Department of Anesthesiology, Division of Neuroanesthesiology, Sher-i-Kashmir Institute of Medical Sciences, Srinagar - 190 011, Jammu and Kashmir
Source of Support: None, Conflict of Interest: None
|Date of Web Publication||11-Jun-2015|
|How to cite this article:|
Ali Z, Khan T, Syed S, Dar BA, Zahoor SA. Resistant hypercarbia in a patient with interstitial lung disease undergoing resection for right parietoccipital meningioma. Saudi J Anaesth 2015;9:335-6
|How to cite this URL:|
Ali Z, Khan T, Syed S, Dar BA, Zahoor SA. Resistant hypercarbia in a patient with interstitial lung disease undergoing resection for right parietoccipital meningioma. Saudi J Anaesth [serial online] 2015 [cited 2020 Jul 5];9:335-6. Available from: http://www.saudija.org/text.asp?2015/9/3/335/154745
A 55-year-old female presented with headache and difficulty in walking. Magnetic resonance imaging showed right parietal meningiomas 8.5 by 6 cm obliterating occipital horn of the right ventricle. A right parieto-occipital craniotomy in right lateral position was planned. A preoperative chest radiograph revealed haziness on left lung with compensatory hyperinflation of the right lung [Figure 1] suggestive of interstitial lung disease. Baseline arterial blood gas (ABG) showed, partial pressure of oxygen of 50 mmHg and partial pressure of carbon dioxide (PaCO 2 ) of 30 mmHg.
|Figure 1: A preoperative chest radiograph revealing haziness on left lung with compensatory hyperinflation of right lung|
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Intraoperatively the more diseased left lung remained downwards receiving more perfusion with a relatively healthy right lung upwards receiving less perfusion. ABG after induction of anesthesia showed a baseline pH of 7.30 and PaCO 2 of 43 mm Hg and end tidal CO 2 (ETCO 2 ) of 31 mm Hg (arterial alveolar gradient of 12 mmHg). After 1 h of positioning, (in the lateral position), PaCO 2 increased to 52 mm Hg with a decrease in pH to 7.16. On increasing the minute ventilation there was a decrease in the ETCO 2 to 23 however the PaCO 2 increased to 52 mm Hg. Serial ABGs showed hypercapnia, resistant to increases in minute ventilation due to defect at alveolar capillary membrane.
This was an associated with an intraoperative brain bulge due to reduced intracranial compliance and hypercarbia. Subsequently, attempts were made to wash out CO 2 by increasing minute ventilation resulting in a reduction of ETCO 2 to 16 mmHg. This was associated progressively with an increase in PaCO 2 to 52 and 67 and a decrease in pH to 7.08 and 6.99. Tracheal extubation was not done, and mechanical ventilation was continued in intensive care unit. In supine position, CO 2 levels decreased to 45 mm Hg over 8 h (because of better ventilation perfusion ratios in the supine position) after which trachea was extubated.
One of the important extrinsic influences on cerebral blood flow (CBF) is arterial CO 2 pressures (PaCO 2 ) CBF is proportional to PaCO 2 between 20 and 80 mm Hg. 
These changes in CBF are caused by pH alterations in extracellular fluid of the brain. Nitric oxide of neuronal origin and prostaglandins are important mediators of CO 2 -induced vasodilation. Our patient had an increased baseline arterial alveolar gradient.
Due to physiological unfavorable position with relatively normal right lung above the left diseased lung, ventilation perfusion mismatch occurred. The arterial alveolar gradient increased as the duration of surgery increased and the patient went into a hypercapnic failure, not responding to increases in minute ventilation. Hypercarbia possibly led to increased brain bulk intraoperatively  though the intracranial pressure became zero when the dural incision was made. To decrease the persistent brain bulge and to improve the operating brain conditions, attempts were made unsuccessfully to maintain CO 2 within 25 ± 2 mm Hg 2 by increasing the minute ventilation.
On the review of literature, we came across hypercapnic failure following aortic valve replacement, managed by Novalung, a device for extracorporeal CO 2 elimination.  Another 44-year-old woman developed refractory hypercapnic respiratory failure despite ventilation with high inspiratory pressure.  A Novalung was used for CO 2 removal.
In conclusion in interstitial lung disease, an unfavorable physiological position increases shunting with an increase in arterial CO 2 and widening of arterial alveolar gradient. Prone position is a useful alternative and may improve the ventilation perfusion ratio. An extra corporeal lung device, novalung may be helpful.
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