Study objectives: Pulmonary edema is a known
postoperative complication, but the clinical manifestations and danger
levels for fluid administration are not known. We studied (1) 13
postoperative patients (11 adult, 2 pediatric) who developed fatal
pulmonary edema, and (2) one contemporaneous year of inpatient
operations at two university teaching hospitals to determine the
clinical manifestations, causes, epidemiology, and guidelines for fluid
Design: Retrospective analysis of 13
patients with fatal postoperative pulmonary edema and one
contemporaneous year of major inpatient surgery.
and methods: Thirteen patients had net fluid retention of at
least 67 mL/kg in the initial 24 postoperative hours and developed
pulmonary edema. Ten were generally healthy while three had serious
associated medical conditions.
results: There was no measurement, laboratory value, or clinical
finding predictive of impending pulmonary edema. The most common
clinical manifestation following the onset of pulmonary edema was
cardiorespiratory arrest (n = 8). Patients had metabolic acidosis
(pH = 7.15 ± .33), hypoxia
(Po2 = 45 ± 18 mm Hg), and normal
electrolytes. The diagnosis of pulmonary edema was established by chest
radiograph and confirmed by autopsy and pulmonary artery pressure
(21 ± 4 mm Hg). The mean net fluid retention was 7.0 ± 4.5 L
(90 ± 36 mL/kg/d) and exceeded 67 mL/kg/d in all patients. Autopsy
revealed pulmonary edema with no other cause of death. Among 8,195
major operations, 7.6% developed pulmonary edema with a mortality of
11.9%. Extrapolation to the 8.2 million annual major surgeries in the
United States yields a projection of 8,000 to 74,000 deaths.
Conclusions: Pulmonary edema can occur within the initial
36 postoperative hours when net fluid retention exceeds 67 mL/kg/d.
There are no known predictive warning signs and cardiorespiratory
arrest is the most frequent clinical presentation. The monitoring
systems currently in use neither detect nor predict impending pulmonary
edema, and as yet, there are no known panic values for excessive fluid
administration or retention.
Abbreviations: TURP = transurethral resection of the