Chest
Volume 115, Issue 5, May 1999, Pages 1371-1377
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Clinical Investigations in Critical Care
Fatal Postoperative Pulmonary Edema: Pathogenesis and Literature Review

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Study objectives

Pulmonary edema is a known postoperative complication, but the clinical manifestations and danger levels for fluid administration are not known. We studied (1) 13 postoperative patients (11 adult, 2 pediatric) who developed fatal pulmonary edema, and (2) one contemporaneous year of inpatient operations at two university teaching hospitals to determine the clinical manifestations, causes, epidemiology, and guidelines for fluid administration.

Design

Retrospective analysis of 13 patients with fatal postoperative pulmonary edema and one contemporaneous year of major inpatient surgery.

Patients and methods

Thirteen patients had net fluid retention of at least 67 mL/kg in the initial 24 postoperative hours and developed pulmonary edema. Ten were generally healthy while three had serious associated medical conditions.

Measurements and results

There was no measurement, laboratory value, or clinical finding predictive of impending pulmonary edema. The most common clinical manifestation following the onset of pulmonary edema was cardiorespiratory arrest (n = 8). Patients had metabolic acidosis (pH = 7.15 ± .33), hypoxia (Po2 = 45 ± 18 mm Hg), and normal electrolytes. The diagnosis of pulmonary edema was established by chest radiograph and confirmed by autopsy and pulmonary artery pressure (21 ± 4 mm Hg). The mean net fluid retention was 7.0 ± 4.5 L (90 ± 36 mL/kg/d) and exceeded 67 mL/kg/d in all patients. Autopsy revealed pulmonary edema with no other cause of death. Among 8,195 major operations, 7.6% developed pulmonary edema with a mortality of 11.9%. Extrapolation to the 8.2 million annual major surgeries in the United States yields a projection of 8,000 to 74,000 deaths.

Conclusions

Pulmonary edema can occur within the initial 36 postoperative hours when net fluid retention exceeds 67 mL/kg/d. There are no known predictive warning signs and cardiorespiratory arrest is the most frequent clinical presentation. The monitoring systems currently in use neither detect nor predict impending pulmonary edema, and as yet, there are no known panic values for excessive fluid administration or retention.

Section snippets

Materials and Methods

There were 13 study patients who, from 1991 to 1996, had postoperative pulmonary edema documented by clinical criteria and characteristic findings on chest radiograph. The diagnosis was confirmed by autopsy in nine patients and by pulmonary artery catheterization in four. Demographic features are shown in Table 1. There were four men and nine women, and the average age (± SD) was 38 ± 21 years. The operations are shown in Table 1. All but one operation (patient 9) were elective. All patients

Postoperative Patients With Fatal Pulmonary Edema

All results are presented as mean ± SD. In eight patients, the initial manifestation of pulmonary edema was cardiopulmonary arrest requiring emergent intubation (Table 1). One patient had intraoperative chest pain, three had acute florid pulmonary edema, and one had acute renal failure. The diagnosis of acute pulmonary edema was established by a diagnostic chest radiograph accompanied by typical physical findings of bilateral rales, a third heart sound, and copious pink frothy sputum in three

Discussion

These data demonstrate that in generally healthy individuals undergoing elective surgery, pulmonary edema may be the initial clinical manifestation of fluid overload. If the pulmonary edema is not recognized and treated promptly, the patients may not survive. Although most textbooks of surgery recognize that excessive postoperative fluid administration can cause pulmonary edema, essentially no guidelines are available as to the quantity of fluid that may lead to such a complication.17 There are

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    Supported by a grant RO1 AG 08575-01A2 fromthe National Institute on Aging, Department of Health and Human Services, Bethesda, MD.

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