1. ARDS after laparoscopic adrenalectomy Present by ： R1 康庭瑞

2. Brief history Name: 陸ＯＯ Chart No.: 0623385 Gender: male Age: 35 y/o BH: ≒ 180 ㎝ BW: 104 ㎏

3. Brief history NIDDM with OHA control for 10 + years HTN for 8 years, poor control Abdominal CT showed a small left adrenal tumor (15 ×14 ㎜ ) Primary aldosteronism (aldosterone-producing adrenal adenoma – Conn ’ s syndrome) was diagnosed Scheduled for laparoscopic adrenectomy on 4/1

4. Brief history Unfortunately, he suffered from dizziness and nausea on 3/23, and he was sent to ER Hypertensive emergency (243/115 ㎜ Hg ) was impressed, and admitted for blood pressure control Arranged laparoscopic adrenectomy on 3/25 after hemodynamic stabilized

5. Laboratory data RBC 4.76 × 10 6 / ㎜ 3 Hb 14.6g/dl Hct 39.9% PLT 256K/ ㎜ 3 WBC 7590 ㎜ 3 Seg 49.7% Eos 7.5% Baso 1.4% Mono 6.7% Lym 34.4% BUN 17.1mg/dl Crea 1.23mg/dl AST 19U/L ALT 32U/L Na 137.1mEq/L K 3.28mEq/L Cl 102mEq/L CRP 0.15ug/dl Tpn-I 0.1ng/ml

6. ECG

7. Chest X-ray (3/23)

8. Induction High airway pressure after intubation Breathing sound decreased and wheezing over right lung field Initial blood gas after the setting of A- line: 麻單 1,CVP insertion 麻單 1 Changed to 8.0 endotracheal tube using tube exchanger smoothly after NG suction

9. Peri-operation Airway pressure still high during the operation Position of the patient: right side lateral decubitus, head and leg-down tilt NG tube did not free drainage to decompression End-tidal CO 2 : 麻單 2 麻單 2 SPO 2 gradually decreased

10. Post-operation Returned to spontaneous breathing but small tidal volume Chest wall paradoxical movement Breathing sound: bilateral rales and wheezing SPO 2 : gradually decreased to 75% ABG: PaO 2 dropped to 47.6 ㎜ Hg, respiratory acidosis

11. Postoperative chest X-ray (3/25)

12. Chest X-ray (3/25 6pm)

13. Chest X-ray (3/26)

14. Chest X-ray (3/27)

15. Chest X-ray (3/28)