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Adult cystic fibrosis for urgent laparoscopic adhesiolysis24-year-old man, 52 kg, for urgent laparoscopic adhesiolysis for distal intestinal obstruction

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Know this first

  • CF patients are colonised, often with drug-resistant organisms; aspiration must be avoided.
  • Poor bile secretion lowers vitamin K-dependent clotting factors; vitamin K may be needed.
  • Ventilate with humidified gas, about 6 mL/kg, modest PEEP, long expiration and low pressures.
  • Subpleural blebs put CF patients at risk of pneumothorax.
  • Avoid nasal instrumentation: polyps and sinusitis are common.

The patient

24-year-old man, 52 kg, for urgent laparoscopic adhesiolysis for distal intestinal obstruction; vomiting. Cystic fibrosis: severe bronchiectasis, FEV1 35% predicted, Pseudomonas colonisation; CF-related diabetes on insulin; liver disease, INR 1.6. Drugs: CFTR modulator, nebulised dornase alfa and tobramycin, insulin, pancreatic enzymes. Vitals: BP 112/70, HR 104, SpO2 93% on air, RR 22, temperature 37.6 °C.

The examiner asks

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  1. Consider

    What are the key issues?

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    • A 24-year-old with severe CF lung disease, diabetes and liver disease, for urgent surgery on obstructed bowel. Patient
    • FEV1 35% with Pseudomonas: little reserve, thick secretions and resistant organisms. Disease
    • Vomiting with obstruction: aspiration into his damaged lungs must not happen. Surgery
    • His INR of 1.6 likely reflects low vitamin K from poor bile flow. Disease
    • Blebs under his pleura make pneumothorax a real risk under positive pressure.

  2. Prepare

    How do you prepare him?

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    • I call the CF team now: recent cultures, current antibiotics and his usual physiotherapy. Disease
    • Airway clearance before theatre, and his nebulised drugs continued.
    • Vitamin K IV for his INR; neuraxial only if clotting allows.
    • Insulin infusion to keep glucose at 140–180 mg/dL.
    • Echo if time allows; severe CF raises lung pressures and can fail his right heart.
    • Contact precautions and his own equipment; Pseudomonas spreads between CF patients. After surgery

  3. Plan

    How will you anaesthetise him?

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    • Rapid sequence induction, rocuronium 1.2 mg/kg; orogastric, not nasal, tubes because of his sinuses. Airway
    • Humidified gases, about 6 mL/kg, modest PEEP and a long expiratory time.
    • Peak pressures kept low; I watch for a pneumothorax during pneumoperitoneum.
    • Regular suction through the tube; a bronchoscope in theatre for secretions.
    • No anticholinergics, to keep his secretions thin. Stem trigger
    • Opioids minimised: paracetamol, local anaesthetic infiltration, early physiotherapy and mobilisation. After surgery

  4. Crisis

    An hour in, SpO2 falls to 86% on FiO2 0.6. Breath sounds are absent over the left lower zone; peak pressure 30 cmH2O, BP 118/68. What do you do?

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    • Likely mucus plugging with left lower lobe collapse. Crisis
    • FiO2 1.0, check tube position, and suction down the tube.
    • Flexible bronchoscopy to clear the plug from that lobe.
    • Then a gentle recruitment manoeuvre, keeping pressures low for his blebs.
    • Humidity checked; dry gas thickens his secretions.
    • After surgery, intensive physiotherapy and HDU. After surgery

  5. Crisis

    Twenty minutes later his right chest goes silent. Peak pressure 42 cmH2O, SpO2 80%, BP 70/40, HR 135. What do you do?

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    • Tension pneumothorax on the right, likely a ruptured bleb under positive pressure. Crisis
    • FiO2 1.0, call help, surgeon releases the pneumoperitoneum.
    • Immediate decompression, no imaging first, then a chest drain.
    • Hand ventilate with low pressures; phenylephrine 50–100 mcg boluses and fluid for BP.
    • If he arrests, the adult arrest algorithm with tension as my reversible cause.
    • Restart surgery only once he is stable; ICU afterwards. After surgery

Fatal mistakes

  • Opioid-heavy analgesia in a man with a weak cough.
  • No airway clearance plan before or after surgery.
  • High airway pressures in damaged, blebby lungs.
  • Nasal tubes through his diseased sinuses.

Checked against: Miller 10e · Stoelting 8e · CDC guideline for isolation precautions: preventing transmission of infectious agents in health care settings (2007) · StatPearls: trauma assessment (2026)

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