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Can anesthesia cause breathlessness and uneasiness during bladder biopsy and TURBT procedures?

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Posted on Wed, 4 Oct 2017
Question: ***Please assign Anesthesia Doctor to answer this question***

Hello Doctor -

I have a question for my Mom regarding her upcoming surgery under General Anesthesia.

Patient History:

1) She is 78 year old woman.
2) She has a bladder cancer and requires regular cystoscopy and bladder biopsy every few months.
3) She has following medical problems apart from the bladder cancer - High Blood Pressure, High Cholesterol, Chronic AFib (Atrial Fibrillation), GERD, Chronic Kidney Disease - Stage 3, GFR 30-59 ml/min.
4) Recent echo-cardiogram was normal with EF of 50-55.
5) She is on medications for her HBP, High Cholesterol, GERD and AFib.
6) She is NOT on the blood thinner because of her bladder tumor and radiation cystitis of bladder wall.

She had bladder biopsy and TURBT procedures in the past:

1) 08/15/2016 - First bladder biopsy with TURBT under General Anesthesia.
2) 11/01/2016 - Second bladder biopsy with TURBT under General Anesthesia.
3) 4/13/2017 - Third Cystoscopy and Ureteroscopy under General Anesthesia.

She was able to tolerate anesthesia very well for the first two procedures (with some minor nausea when she woke up), but she was not able to tolerate anesthesia well for the third procedure.

She was feeling suffocated - was not able to breath easily after she woke-up from the general anesthesia. She was complaining a lot of difficulty in breathing and uneasiness in the chest area.
She experienced this problem for 3-4 hours after she woke-up from the anesthesia.
She started feeling better after 3-4 hours and the problem went away.

The doctor said her vitals were normal and they also tried CPEP to help her with her breathing problem, but it didn't work.

She suffered this problem for 3-4 hours and doctor said she is just frightened and so feeling breathless.

She had this procedure under general anesthesia two time in the past and never had this issue.

We have following questions:

1) What could be the possible causes for this problem?
2) She has another procedure scheduled under general anesthesia this week. What can be done proactively to avoid this problem happening again?
3) If this happens again, what should be done so that she does not need to suffer for 3-4 hours again?
4) Was this problem due to the reaction from the anesthesia medicine?
5) Was this problem due to some underlying health issue we don't know of? What tests will help?

Thank you very much for your time and expert advice!


doctor
Answered by Dr. Matt Wachsman (8 hours later)
Brief Answer:
Good question. wrong doc.

Detailed Answer:
Anaesthesiologists can't know everything; clinical pharmacologists with primary specialty in internal medicine can. They are likely to say, "secretions." and that's it.

Here's how. I organize thoughts not as little sentences and paragraphs, but in multidimensional paths.
The path starts with the fork of going for lung or for not lung.

We don't have the information to be able to say what happened and how to prevent it, but I can outline a path for all the possibilities and how you move along it to be able to get to all the answers you want. The first pathway is to decide if it is a lung problem or something else. Signs of lung problem are pretty easy to see. Besides the obvious "difficulty breathing; feeling out of breath", there are objective findings of lung problem this would be not enough oxygen getting in and/or having to work harder to get to that oxygen. The former is implied to NOT BE THE CASE because VITAL SIGNS NORMAL which would always include both the oxygenation level and breathing rate. Within the group of lung problems are lack of air, lack of muscle function on the lung, airway problems, and circulation problems which should probably NOT be listed as lung (see below). She has lack of muscle problems. She is not 20 years old. This is fixable in 2 weeks with INCENTIVE SPRIROMETRY. Builds up muscle tone. There is lack of lung tissue. If she smokes she has this. Not fixable. the incentive spirometry helps. It's never done. Don't ask me. Airway problems are demonstrable by listening. It might be subtle that isn't common. Mostly it's obvious wheeze or secretions. There are medicines for this. They can be used ahead of time but the ones for secretion interact with those for anesthesia and are cautiously generally used by the anesthesiologist if needed during the surgery (they are well trained on how to manage this; I didn't say they don't know their job; it is complex and has to be done at the time and cannot be guessed at ahead of time).
Basically, if it is lung, the anesthesiologist will take care of it, and if it was starting in recovery room they would have seen, evaluated, and treated it. If it was an hour after the recovery room, they should have been called in for an opinion. If it was a day later, then it probably wasn't directly due to the surgery and they aren't relevant. Except for secretions which can peak a day after getting a tube down the throat.

The last part of the lung issues is post surgical pneumonia. This would show signs of infection with fever, elevated white count, changes on the x ray, and secretions.

then on the non-lung, it would be circulation. First thing on the path is heart problems because, like, heart problems.

But, before we get there, we move out from the lung on the path. There is the circulation within the lung and blood clots in the lung cause problems as outlined and are generally not noticed. They are preventable and a lot is known about it. Generally, nearly always, prevention is done. Blood clots used to be an every day occurrence, they are now rare. But, everything else with circulation is common.

Heart trouble lowering the flow through the lung is common but mainly because the symptoms SOUND LIKE A HEART ATTACK, it is plain malpractice to not have her heart checked out prior to the next surgery. Heart trouble. The evaluation would look for basically all of it.

Basically, everything else on the fork of the path that is not lung is circulation and there is heart trouble and then there is increased fluid pressure in the lung. Then, anything that increases fluid volume, including just giving too much intravenously which is especially common with bladder surgery and can be not only IV but also from the fluid put into the bladder to flush it out is probably the most common cause of shortness of breath. Heart, lung, kidney, liver and mainly giving too much fluid all cause fluid overload. It is easy to see and easy to miss and easy to treat even if the person doesn't have kidneys. It is NOT an anaesthesiologist issue, and is the most likely cause of problems of breathing occurring after and not during surgery.

Finding the cause which is outlined by this pathway basically tells you the rest. Incentive spirometry is a good idea .not done. don't ask me. Finding about heart issues is nearly always done. And then there can just be irritation of the area which then causes secretions a few hours later. This is probably preventable with any asthma medicine and monteleukast is FDA approved for all inflammatory conditions of the lung basically. But they never use it preventatively except for things where it isn't really preventative (ongoing asthma). don't ask me. It has about no down side and might prevent secretions.
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Matt Wachsman (7 hours later)
Hello Dr. Wachsman -

Thanks your very much for your time and for the detail answer.

My Mom has a surgery tomorrow morning. So, looks like some of the things like INCENTIVE SPRIROMETRY is not going to help in one day.

She did have echo-cardiogram done two weeks back and was normal with the EF of 50-55. She had chemical stress test done last year in October, 2016.

Wondering, could the reversal agent used after anesthesia be the cause of the problem?

We will let the Anaesthesiologists know about the problem she faced last time and will request him/her to watch her closely during and after the surgery.

Is there something else we can request Anaesthesiologists tomorrow which may help prevent this issue?

Thanks again for your expert advice and time! And appreciate your help!

doctor
Answered by Dr. Matt Wachsman (35 minutes later)
Brief Answer:
well, they are doing a pretty good job.

Detailed Answer:
Cardiac evaluation. Check and Check.

Watching closely for fluid is all you can do. And it's good enough. A simple chest x ray will show whether it is present or not during the problem if it were to occur. If they are doing bladder irrigation afterwards, and they probably have to, then they cannot entirely control how much fluid gets in, but they can give diuretic if she gets too much in. The shortness of breath is alarming, but easily handled and shouldn't have long term effects. Same thing happened to my dad and he lived another 20 years. It might have happened before and been corrected about as fast as it can be.

There can be an allergic response to any medicine and it isn't definite, or even likely that was the cause last time (they would have noted wheeze; it generally lasts less than 24 hrs even untreated but lasts a bit longer).

The reversal agent most likely is diuretic FUROSEMIDE otherwise known as lasix since it typically lasts 6 hrs. (sitting up helps a bit, too and works immediately).
If there is an allergic reaction, steroids... but they take hours to begin working and peak effect takes a good 24 hrs.
Might be anxiety or pain. Morphine can cause allergy (uncommon) but otherwise it lowers pain/anxiety, and lowers fluid overload by a mild degree.

Overall, main point is it sounds like they are doing a good job.
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Matt Wachsman (6 hours later)
Thank you very much Dr. Wachsman.

BTW, we just received a chest x-ray report for the chest x-ray done couple of days back.

The report indicates - "There is increased interstitial markings in bilateral lung fields suggesting chronic changes. No focal infiltrate.....
Impression: No infiltrate, effusion, or acute findings identified."

1) Is this something need to be concerned about for the general anesthesia?

2) Also, if the duration between two procedures with general anesthesia is short (e.g. 3-4 months) can cause any long-term/short-term issues?

Thanks again for all your help and advice!

doctor
Answered by Dr. Matt Wachsman (3 hours later)
Brief Answer:
These are really good questions

Detailed Answer:
Which is why there are limitations on how much I can answer them without being there. INterstitial markings are quite common especially if the person ever smoked cigarettes. They do not necessarily mean much. They can occur with fluid overload BUT there is MORE to the picture in that case: 1) the main vessels are also enlarged 2) generally so is the heart 3) the vessels are not only more prominent BUT the pattern of this is changed from normal with the vessels that are higher up in the chest also having enlargement--if there isn't fluid OVERload, then the fluid goes to the bottom and the bottom vessels of the lung are much bigger than the upper ones. Because the report mentions NOTHING connected with fluid overload, we can probably say THERE ISN"T ANY. So, x ray doesn't say all that much wrong.

Second point. I would say 3 months isn't all that soon after an operation. So, it shouldn't make much of a difference.
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
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Can anesthesia cause breathlessness and uneasiness during bladder biopsy and TURBT procedures?

Brief Answer: Good question. wrong doc. Detailed Answer: Anaesthesiologists can't know everything; clinical pharmacologists with primary specialty in internal medicine can. They are likely to say, "secretions." and that's it. Here's how. I organize thoughts not as little sentences and paragraphs, but in multidimensional paths. The path starts with the fork of going for lung or for not lung. We don't have the information to be able to say what happened and how to prevent it, but I can outline a path for all the possibilities and how you move along it to be able to get to all the answers you want. The first pathway is to decide if it is a lung problem or something else. Signs of lung problem are pretty easy to see. Besides the obvious "difficulty breathing; feeling out of breath", there are objective findings of lung problem this would be not enough oxygen getting in and/or having to work harder to get to that oxygen. The former is implied to NOT BE THE CASE because VITAL SIGNS NORMAL which would always include both the oxygenation level and breathing rate. Within the group of lung problems are lack of air, lack of muscle function on the lung, airway problems, and circulation problems which should probably NOT be listed as lung (see below). She has lack of muscle problems. She is not 20 years old. This is fixable in 2 weeks with INCENTIVE SPRIROMETRY. Builds up muscle tone. There is lack of lung tissue. If she smokes she has this. Not fixable. the incentive spirometry helps. It's never done. Don't ask me. Airway problems are demonstrable by listening. It might be subtle that isn't common. Mostly it's obvious wheeze or secretions. There are medicines for this. They can be used ahead of time but the ones for secretion interact with those for anesthesia and are cautiously generally used by the anesthesiologist if needed during the surgery (they are well trained on how to manage this; I didn't say they don't know their job; it is complex and has to be done at the time and cannot be guessed at ahead of time). Basically, if it is lung, the anesthesiologist will take care of it, and if it was starting in recovery room they would have seen, evaluated, and treated it. If it was an hour after the recovery room, they should have been called in for an opinion. If it was a day later, then it probably wasn't directly due to the surgery and they aren't relevant. Except for secretions which can peak a day after getting a tube down the throat. The last part of the lung issues is post surgical pneumonia. This would show signs of infection with fever, elevated white count, changes on the x ray, and secretions. then on the non-lung, it would be circulation. First thing on the path is heart problems because, like, heart problems. But, before we get there, we move out from the lung on the path. There is the circulation within the lung and blood clots in the lung cause problems as outlined and are generally not noticed. They are preventable and a lot is known about it. Generally, nearly always, prevention is done. Blood clots used to be an every day occurrence, they are now rare. But, everything else with circulation is common. Heart trouble lowering the flow through the lung is common but mainly because the symptoms SOUND LIKE A HEART ATTACK, it is plain malpractice to not have her heart checked out prior to the next surgery. Heart trouble. The evaluation would look for basically all of it. Basically, everything else on the fork of the path that is not lung is circulation and there is heart trouble and then there is increased fluid pressure in the lung. Then, anything that increases fluid volume, including just giving too much intravenously which is especially common with bladder surgery and can be not only IV but also from the fluid put into the bladder to flush it out is probably the most common cause of shortness of breath. Heart, lung, kidney, liver and mainly giving too much fluid all cause fluid overload. It is easy to see and easy to miss and easy to treat even if the person doesn't have kidneys. It is NOT an anaesthesiologist issue, and is the most likely cause of problems of breathing occurring after and not during surgery. Finding the cause which is outlined by this pathway basically tells you the rest. Incentive spirometry is a good idea .not done. don't ask me. Finding about heart issues is nearly always done. And then there can just be irritation of the area which then causes secretions a few hours later. This is probably preventable with any asthma medicine and monteleukast is FDA approved for all inflammatory conditions of the lung basically. But they never use it preventatively except for things where it isn't really preventative (ongoing asthma). don't ask me. It has about no down side and might prevent secretions.