M Elburjo, A Halsa, A Zidan
hyadatid, hypertonic saline, pulmonary, scolicidal agents
M Elburjo, A Halsa, A Zidan. Pulmonary Hydatid Disease Intra-Operative Hypertensive Crisis. The Internet Journal of Thoracic and Cardiovascular Surgery. 2002 Volume 6 Number 1.
A nine year old child presented with recurrent mild cough and fever. Chest X-ray of the chest showed two well defined radio-opaque shadows one in each lobe of the left lung. All routine investigations were within normal limits, which included blood tests and serological tests but computed tomography of the chest proved that they are cystic lesions and detected other masses in the mediastinum or in the upper abdomen. One cyst was aspirated and 20% hypertonic saline was used as a scolicidal agent. Severe hypertensive crisis developed and the blood pressure reached up to 220/190 and pulse rate to 170/minute. The crisis was managed successfully and the other cyst was removed intact by Barrett's method. The patient was discharged in good condition and followed for 6 months. There were no further hypertensive attacks and no medication was needed. We present this case because of the dangerous condition that occurred and to initiate any response from colleagues round the globe and to answer the important questions: Is it always necessary to use scolicidal agents or not? Can hypertonic saline cause hypertensive crisis?
Hydatid disease is common in Libya with prevalence of 2% (1). Surgery is still the treatment of choice. Controversy still exists about the use of scolicidal agents to prevent recurrence in the pleural cavity and the thoracotomy wound (2). Among the agents used in the past: formaldehyde diluted to 10% (3), silver nitrates and hypertonic saline (HS). The basic idea behind HS use is the creation of an osmotic gradient that kills the scolices. Hypertonic saline is regarded safe by many authorities (2, 4,5). To our knowledge, there are no reports regarding any adverse effects of this drug.
A nine year old child was referred from the children hospital in Tobruk city in eastern part of Libya. We saw the child at the Al Batnan Medical center Surgical Department, Tobruk, Libya (the first author operates in this center by invitation). The reason for reference was; recurrent attacks of cough and fever and the child was discovered to have two cystic lesions in his left lung (one in each lobe as seen on a chest film and computed tomography of the chest). No other radio-opaque shadows were seen.
The general condition of the child was good. The blood and the serological tests were normal. The blood pressure 120/80- pulse 100/miute regular, respiratory rate 16/minute, ECG was normal. Abdominal ultrasound was also normal. The diagnosis of pulmonary hydatid was made on the above observations and the child was scheduled for surgery.
On pre-anesthetic check up the vital signs were the same as above. Anesthesia was induced by 100% Oxygen, 200mcg fentanyl, 6omg diprivan, and 15mg tracurium. The patient was intubated by 6mm Murphy eyed cuffed endotracheal tube, then the child was put on his right lateral position for left thoracotomy and anesthesia maintained by 50-50- oxygen-nitrous oxide, halothane 0.3% and tracurium. The ventilator was set on IPPV closed pediatric circle. Vt 320cc , Foi 15/miute, Mv 5L, flow 4L Paw 25 bars, Spo2 100%, capnography was normal.
Postero-lateral left thoracotomy was done in the usual way and the chest cavity easily entered. There were no strong adhesions. There were two hydatid cysts,one in each lobe. The lung was mobilized, the operative field was packed to prevent contamination and the lower lobe dealt with first by attempting to remove its contained cyst by Barrett's method but ruptured during this procedure so the fluid immediately sucked out, the membranes removed and 20% hypertonic saline was poured in the cavity and sucked out repeatedly. Few minutes later, the anesthetist observed that the child developed high blood pressure (BP) 220/190, pulse 170/minute. This high blood pressure was treated by intravenous (IV) sodium nitroprusside diluted in normal saline 0.5mcg/kg/minute and increased by 0.5mcg every 3-5 minutes; hydralazine 5mg and Lasix 20mg were given IV also. It took 40 minutes to bring this high BP down to 120/74 and pulse to 90/minutes regular.
During this period, the other cyst was removed easily intact by Barrett`s method and the chest closed in the normal way lifting two chest tubes 20FG for apical and basal drainage and connected to a double chamber underwater seal. Reversal of anesthesia was undertaken in the usual way and the patient was fully conscious before leaving the operating room
The child made a very good uneventful recovery. The chest tubes were removed on the fourth day after full expansion of the lung. The child went home on the 10th day after removal of the stitches. Sixth months later the child was good, had no hypertensive problems or any complaints and was very active.
Surgery is the treatment of choice for hydatid disease. The best approach to an intact cyst is its removal by Barrett's technique. Following this method avoids the use of any scolicidal agent, if it is done successfully. Long-term drugs, such as albendazole, are also avoided (2,4,5,6,8,9,10,).
In our experience over the last 18 years we attempt the above method first and only resort to the use of hypertonic saline- the only agent we used over this period. We had recurrences in only two patients (only if ruptures occurred and in cases of huge cysts and cysts in difficult locations). We found, like others, that hypertonic saline is safe and effective (2,4,5,7,11)
The question is if it is necessary to use a scolicidal agent? Experience accumulated over the years showed that the recurrence of pulmonary hyadtid cysts is very rare (8,9,12,13) unlike the hydatid liver disease or other cysts in other abdominal locations in which cases the use of scolicidal agents seems more logical. We think that the chest can be washed thoroughly by normal saline provided that we pack the thoracotomy wound perfectly.
There are no comparative studies between different types of agents that tell us which to use on firm bases. All kill the parasite but no other study telling us that if these agents are not used the recurrence will be high.
M. Elburjo P.O.BOX 15019 Benghazi Libya Email:firstname.lastname@example.org