Abstract

Keywords

elderly patients; general anesthesia; hypoalbuminemia; noninvasive blood pressure cuff; peripheral edema;

To the Editor,

Automatic cycling noninvasive blood pressure (NIBP) devices have been widely used during anesthesia. Although it is generally safe, complications may occur.¹

An 86-year-old woman, 40 kg in weight, 146 cm in height, and body mass index of 18.7 kg/m², was admitted because of ureteral stones. She received hypertensive medication regularly, and the initial laboratory data revealed anemia (hemoglobin 8.8 g/dL), hypoalbuminemia (1.8 g/dL), hyponatremia (108.2 mmol/L), and hyperkalemia (5.39 mmol/L). Severe hypoalbuminemia (serum albumin level of <2.5 g/dL)² and malnutrition (body mass index < 20 kg/m²)³⁻⁵ were also diagnosed. After 2 weeks, elective vesicolithotripsy in supine lithotomy position was scheduled. The preoperative blood tests showed concentrations of blood urea nitrogen 21 mg/dL, creatinine 0.49 mg/dL, sodium 128.1 mmol/L, potassium 5.42 mmol/L, glucose 166 mg/dL, and hemoglobin 10.2 g/dL after receiving blood transfusion with packed red blood cell 2 units. In the operating room, a peripheral venous catheter was inserted in the right arm. A NIBP cuff was placed on the upper left arm in full extension and was automatically cycled every 5 minutes for a 90-minute procedure. There were about 10 seconds longer durations of tourniquet inflation and higher systolic blood pressure up to 180 mmHg preopderatively and 120–140 mmHg perioperatively than a normal patient. General anesthesia with endotracheal intubation was induced with thiamylal, succinylcholine, and lidocaine. General anesthesia was maintained with sevoflurane in oxygen to keep bispectral values between 40 and 60. Postoperatively, pronounced swelling of the left arm and hand distal to the NIBP site was found (Figure 1). Peripheral edema may be caused by several factors, such as allergic reaction, obstruction of blood flow, hypoalbuminemia, congestive heart failure, liver, and kidney disease. Malfunction of venous return seems to be an important influence. Hypoalbuminemia is common in the elderly who are institutionalized.²Hydrostatic pressure in the blood vessels moving fluid out into interstitial space is normally counterbalanced by colloid oncotic pressure holding fluid in the vascular space. This oncotic pressure is generated by a high concentration of proteins in the blood, notably albumin. For this malnutrition patient with severe hypoalbuminemia, critical constriction occurred beneath the NIBP cuff,¹ leading to severe acute peripheral edema of the distal left arm and hand during a short period (90 minutes) of unconsciousness (under general anesthesia). Therefore, the swollen arm and hand was elevated and allowed to rest on a comfortable surface, above the level of her heart to enhance the lymphatic drainage that removes the excess fluid in the interstitial space. Peripheral edema of the left arm and hand partially resolved 3 hours later and completely subsided by the next day.

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Figure 1. Pronounced swelling of the left arm and hand distal to the automatic cycling noninvasive blood pressure cuff site in a patient with severe hypoalbuminemia under general anesthesia.

In full extension of the arm, standard placement of NIBP cuff with automatic cycles every 5 minutes is well tolerated on daily intraoperative practice without adverse effects. However, an automatic cycling NIBP cuff may develop a significant tourniquet effect, complicated with acute peripheral edema on the arm of a patient with severe hypoalbuminemia while under general anesthesia. The appropriate selection size of blood pressure cuff and the fitting of upper arm are very basic and necessary to avoid this tragedy.

Conflicts of interest

The authors declare no conflicts of interest.