INTRODUCTION: Cystic fibrosis (CF) implicates a serious pulmonary compromise which makes patients very complicated to ventilate and a high risk of complications when scheduled for urgent abdominal surgery under general anaesthesia.

CASE REPORT: This 48-years old male patient (Weight: 85kg Height: 175cm) with CF, presented a severe lung affectation (FEV1 17%; VCF 45,5%; FEV1/VCF 30%. Thorax CT Scan: TLC 6142 ml³ (9,6% emphysema)) and was on lung transplantation list for 10 months. He developed an acute respiratory failure that indicated his admission in the ICU, and required mechanical ventilation and tracheostomy. Two weeks after, he was diagnosed of a subphrenic abcess due to an intestinal perforation and was scheduled for right colectomy. The patient was transferred sedated and ventilated from the ICU to the OR, after administrating inhaled salbutamol. Fentanyl, propofol and rocuronium were used to deepen anaesthesia. Maintenance was ensured with sevoflurane, fentanyl and cisatracurium. Mechanical ventilation required high IFO2 (80%), with a protective ventilation (TV 400mL, RR 20/min but no PEEP to avoid traumatic rupture of bullae) with good clinical tolerance. The persistence of high ventilator pressure (38mmHg) justified the placement of a temporary VAC, which was removed after 1 week to avoid an increase of ventilatory pressure associated with high intra-abdominal pressure. Patient returned to the ICU at the end of surgery with no further problems. On day 20, due to a difficult weaning from mechanical ventilation, he was transferred under mechanical ventilation on his tracheostomy (PSV + CPAP) to the pneumology service, and discharged from hospital after 3 months.

DISCUSSION: In patients with CF, emergent surgery increases highly the morbidity. Intraoperative management is the key to good results. Mechanical ventilation should limit pulmonary pressure (lower tidal volume and higher respiratory frequency are tolerated better than PEEP in this case). The surgical team should as well take into account the risk of high intra-abdominal pressure, which limits lung expansion. Coagulation should be closely monitored, since it can be altered secondary to malabsorption and liver disease, which can increase bleeding.

CONCLUSSION: CF is increasing among adults scheduled for surgery. Anesthetic management should protect the already sick lung, and this involves a perfect knowledge of all factors that alter lung compliance and treatments to avoid respiratory complications. 

09 / Anesthetic management of an adult patient with cystic fibrosis for acute abdominal surgery (A case report)