Flash pulmonary oedema following arteriovenous fistula surgery: rapid assessment and treatment is key to break the vicious cycle

Abstract

An early adolescent boy with chronic kidney disease on haemodialysis was referred to the surgical clinic for the creation of an arteriovenous fistula. He was undergoing treatment for dilated cardiomyopathy and extrapulmonary tuberculosis. The patient was haemodynamically stable during the procedure, but he developed rapidly progressing dyspnoea, tachycardia and tachypnoea about 10 min after the vessels were declamped. His blood pressure rapidly rose above 220/120 mm Hg and saturation dropped below 90%. A multidisciplinary team (MDT) constituted of surgeons, nephrologists and intensivists was quickly activated. The patient was put on a mechanical ventilator and resuscitated with parenteral antihypertensives, diuretics, amiodarone and haemodialysis. The patient improved clinically and was discharged on the third postoperative day. Thus, a rapidly activated MDT approach was key in breaking the vicious cycle caused by hypertensive crisis, myocardial dysfunction and impending ventilatory failurethat occurred following access surgery.