Negative pressure pulmonary edema postextubation following medial nerve repair with sural graft surgery in a young patient: A case report

RATIONALE: Negative pressure pulmonary edema (NPPE) is a serious well-described pulmonary complication. It occurs after an intense inspiratory effort against an obstructed or closed upper airway and generates a large negative airway pressure, leading to severe pulmonary edema (transvascular fluid filtration and interstitial/alveolar edema) and hypoxemia. We present a case of NPPE following general anesthesia in a patient who underwent median nerve neurorrhaphy with graft from lower left limb (sural nerve) due to sharp injury. PATIENT CONCERNS: A 39-year-old Hispanic male was admitted to the Hospital Universitario de San José and scheduled to undergo a median nerve neurorrhaphy under general anesthesia. Preoperative vital signs, physical examination, and laboratory assessments were unremarkable. At the end of surgery, anesthetic agents were ceased after patient responded to commands and maintained eye contact. However, immediately after extubation, anesthesia care providers observed marked respiratory distress and rapid development of hypoxia. DIAGNOSES: After extubation, patient presented multiple episodes of hemoptysis, tachypnea (25 per minute), blood oxygen saturation (SpO(2)) of 82% and abundant bilateral pulmonary rales. A baseline chest x-ray revealed symmetric parenchymal opacities with ground-glass attenuation and bilateral multilobar consolidations patterns. The diagnosis of NPPE was established and supportive treatment was initiated. INTERVENTIONS: The patient received noninvasive mechanical ventilation with a PEEP at 10 cmH(2)O, intravenous furosemide (20 mg.) every 12 hours, and fluids restriction. Patient remained in PACU for continuing monitoring and laboratory/imaging follow-up testing until next morning. OUTCOMES: On postoperative day 1, patient responded satisfactorily to supportive treatment and transferred to the general care floor; oxygen supplementation was discontinued 12 hours after extubation time. On postoperative day 3, after the evaluation of a chest x-ray, patient was discharged to home in stable conditions LESSON: The occurrence of NPPE in the perioperative setting could be successfully managed with supportive regimens, effective clinical team coordination, and awareness of the importance of its rapid diagnosis.