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Flash pulmonary oedema following arteriovenous fistula surgery: rapid assessment and treatment is key to break the vicious cycle
  1. Jagadeep Ajmera,
  2. Manjunath Maruti Pol,
  3. Belmin Winston Gysley and
  4. Bhanupradeep Yadav
  1. Department of Surgical Disciplines, AIIMS, New Delhi, India
  1. Correspondence to Dr Manjunath Maruti Pol; manjunath.pol{at}


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.

  • Vascular surgery
  • Mechanical ventilation
  • Dialysis
  • Chronic renal failure
  • Anaesthesia

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  • Contributors MMP and JA conceived the design. MMP was the first operating surgeon; the patient was evaluated, worked up and discussed by JA, BWG and BY. MMP, JA and BY were involved in radiological discussion and arriving at diagnosis. The patient was operated by MMP, JA, BWG and BY. MMP, JA and BWG collected the operating steps. Demography of the patient, clinical details and image editing was done by BWG, JA and BY, and further it was analysed by MMP. Manuscript was prepared by MMP, JA, BWG and BY. Editing of image was performed by BWG and JA. Case report was written, critically analysed, revised and uploaded by JA and MMP. Final approval of the case report is provided by MMP, JA, BWG and BY.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Case reports provide a valuable learning resource for the scientific community and can indicate areas of interest for future research. They should not be used in isolation to guide treatment choices or public health policy.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.