Sivelestat Improved Oxygenation in a Patient Who Suddenly Developed Hypoxia During Surgical Resection of Perforated Colon

Sivelestat is a potent inhibitor of neutrophil elastase activity. We report a patient who suddenly developed hypoxia during surgery, which improved by the administration of sivelestat. A 72-year-old woman underwent emergency resection of a perforated colon that was capsulated by mesenterium. During the surgical manipulation, the capsule ruptured, causing spillage of dirty discharge into the abdominal space. A few minutes after it ruptured, her oxygen saturation (SpO2) suddenly dropped from 100% to 94%. Ten minutes after it ruptured, administration of sivelestat, 12 mg/hr, was started. Her SpO2 gradually increased and her Arterial Blood Gas (ABG) values improved. After the surgery, the patient was admitted to the Intensive Care Unit (ICU). Her trachea was extubated 30 hours after admission to the ICU. There were no remarkable pulmonary complications after extubation. Sivelestat administration was continued for four days. The time course of oxygen desaturation and her blood parameters suggested that systemic circulation of an endotoxin induced the secretion of elastase from neutrophils, which in turn caused sudden desaturation. If the patient had not been treated with sivelestat, there was a high possibility that she could have developed Acute Lung Injury (ALI) due to the hypoxia. When a patient with risk factors for developing ALI develops oxygen desaturation during surgery, administration of sivelestat may improve the patient’s oxygenation and prevent the development of ALI. Central Suzuki et al. (2014) Email: Int J Clin Anesthesiol 2(2): 1025 (2014) 2/4 38 mmHg and PaO2 142 mmHg with a tidal volume of 600 ml and a respiratory rate of 10min-1 (Figure 2). During the surgery, the surgeons confirmed that the sigmoid colon was perforated. However, they observed that the mesenterium covered the perforated colon like a capsule. Although the surgeons carefully manipulated the capsule, the capsule ruptured. Dirty fluid and stool spilled into the abdominal space. The surgeons notified the anesthesiologist that the capsule had ruptured (Figure 2). A few minutes after the capsule ruptured, her SpO2 value suddenly dropped from 100% to 94%. Her ABG values were PaCO2 39 mmHg and PaO2 75 mmHg under 50% of oxygen (Figure 2). Her systolic blood pressure decreased from 140 mmHg to 110 mmHg. We reduced the concentration of sevoflurane from 2.5% to 1%, and this stabilized her hemodynamics at an acceptable level. We suspected that the oxygen desaturation occurred due to the release of an inflammatory mediator such as elastase from neutrophils in the ruptured capsule. Ten minutes after the capsule ruptured, we began to administer sivelestat at 12 mg·hour-1 (Figure 2). Thirty minutes later, the perforated colon was successfully resected (Figure 2). The SpO2 value gradually increased and was 95% at 10 minutes after the start of sivelestat administration. At fortyfive minutes after the start of sivelestat administration, the SpO2 value was 99% and her ABG values showed a PaCO2 of 39 mm Hg and PaO2 of 120 mm Hg (Figure 2). The change in oxygen saturation before, during and after the surgery is shown in Figure 2. At the end of the surgery which occurred 140 minutes after rupture of the capsule, her ABG values were PaCO2 37.9 mm Hg, PaO2 205 mmHg, BE -1.4 mmol·l-1, and Hb 9.9 g·dl-1with a tidal volume of 600 ml and respiratory rate of 10min-1, with 50% oxygen (Figure 2). The duration of anesthesia was 275 min, and the total volume of fluid infused was 3100 ml. Four packs of fresh frozen plasma were administered during the surgery. During the anesthesia, total blood loss was 500 ml and urine output was 300 ml. The patient was admitted to the Intensive Care Unit (ICU) after the surgery. Blood examination performed upon arrival at the ICU revealed that her WBC count had decreased to the normal range (Table 1). Chest roentgenograms obtained just after the patient arrived at the ICU and at 6 hours after arriving at the ICU revealed no signs of ALI (Figures 3 & 4). In the ICU, the patient’s breathing gradually stabilized. Eighteen hours after admission to the ICU, her trachea was extubated. Sivelestat administration was continued for 4 days after the surgery. There were no respiratory complications after the surgery.