Postoperative pneumonia in a patient with preoperative upper airway infection

A 24-year old woman was scheduled to undergo a Le Fort I osteotomy and SSRO. She had been administered antihistamines due to allergic rhinitis since elementary school. Three weeks prior to this admission, she had an upper airway infection (UAI) with fever (37.5°C), cough, and a congested nose. Physical examination was unremarkable and blood examination and vital signs were within normal limits, except for the above mentioned conditions. No premedications were administered. Prior to anesthesia, electrocardiographic monitoring and oxygen saturation monitoring were established. An automated system to measure blood pressure was placed on the right arm and set to cycle and recorded at 2.5 min intervals. The system also monitored the heart rate, the concentration of inhaled anesthetic agents via artificial nose, expired CO₂ concentration via artificial nose, and body temperature. Anesthetics (midazolam ; 10 mg, vecuronium bromide ; 5 mg, fentanyl citrate ; 0.2 mg, droperidol ; 2.5 mg) were injected intravenously. After nasotracheal intubation, the lungs were ventilated mechanically with nitrous oxide 4 l/min, oxygen 2 l/min, and sevoflurane 1.5-2.0%. A nasogastric tube was placed at 55 cm. Before surgery was started, lidocaine with epinephrine was infiltrated at the surgical field. The duration of the operation was 2 hours. The duration of anesthesia was 3 hours. After intravenous injection of naloxone and recovery from anesthesia, extubation was performed. The total doses of fentanyl, midazolam, vecuronium, and lidocaine with epinephrine were 0.5 mg, 10 mg, 5 mg, 16 ml, respectively. Blood loss was 130 ml. Urine volume was 300 ml. The fluid volume was 1,000 ml. Intraoperative respiratory complications such as laryngospasm, bronchospasm, and breath holding, did not occur. Three days after the operation, she was diagnosed with postoperative pneumonia with fever (39.1°C), due to a slight rales with right lower lobe breath sounds and a chest radiography showed shadow at the right inferior lung fields. SpO₂ was 99% under room air. She was administered cefazolin sodium (Cefamezin®) intravenously as an alternative antibiotic. However, body temperature was still high (38.5°C). Five days after the operation, the antibiotics were changed to piperacillin sodium (Pentcillin®) intravenously and clarithromycin (Clarith®) orally. The patient showed improvement 7 days after the operation. Although there is good evidence supporting that head and neck surgery appear to be the major procedure-related risk factors conferred with high risk postoperative pulmonary complications, insufficient evidence supports UAI as the risk factors. However, we recommend that patients with significant preoperative symptom of URI should have their surgery postponed.