Intraoperative respiratory failure in a patient after treatment with bleomycin: previous and current intraoperative exposure to 50% oxygen

Patients treated with bleomycin (BLM) are at risk of developing acute respi ratory distress syndrome (ARDS) post-operatively, and this has been associa ted with high intraoperative concentrations of oxygen. We report progressiv e arterial desaturation noticeable 2 h after the start of a 4-h radical nec k dissection for which the anaesthesia included 50% O-2 in N2O. The patient had received two courses of bleomycin within the previous 2 months and had undergone an uneventful right hemiglossectomy under shorter but otherwise similar anaesthesia 4 weeks previously. His pulmonary function tests before the second procedure showed a slight depression of diffusing capacity (DLc o) to 80% of predicted and minimal airway obstruction consistent with his h istory of smoking. The pulse oximetric reading during his second procedure reached 75%, but rose to 95% after treatment with methylprednisolone, salbu tamol and inspired O-2 concentrations between 80% and 100%. By the end of t he procedure, he satisfied the criteria for ARDS and was transferred to the ICU, where he developed bilateral pneumonia, deteriorated and died of mult iple organ failure. This case suggests that the risk of hyperoxic pulmonary damage in patients exposed to bleomycin may increase not only with the deg ree and duration of hyperoxia in a given exposure, but also with the latent effects of recent previous exposure. Near normality of pulmonary function tests cannot be taken as reassurance, and small changes may have more adver se prognostic significance than in patients who have not been exposed to bl eomycin.