A 37-year-old man with suspected tuberculosis and severe cavitary lung disease presented with an acute abdomen with pneumoperitoneum requiring emergent exploratory laparotomy. The patient presented with dysphagia, recurrent regurgitation, pancytopenia, treatment refractory elevated International Normalized Ratio (INR). His compromised respiratory status, likely to worsen under positive pressure ventilation, along with a high risk of aspiration of gastric content and coagulopathy during emergent abdominal surgery, required general anesthesia. In patients with extensive pulmonary tuberculosis and large lung cavernous lesions, general anesthesia increases the risks of dissemination of the disease, barotrauma, and impaired gas exchange, all of which may lead to respiratory failure. Available literature is scarce and focuses on employing regional anesthesia and avoiding mechanical ventilation whenever possible. Our plan included taking the patient to a negative pressure room with limited personnel wearing individual protective equipment; performing videolaryngoscopy with maintained adequate respiratory drive and endotracheal intubation under sedation and topical anesthesia of the vocal cords; careful titration of pressure support for normocapnia and normoxemia. Throughout surgery, peak pressures and respiratory mechanics were continuously monitored, and the patient maintained lung-protective tidal volumes and low airway pressures. He was successfully extubated in the operating room; no respiratory support was necessary in the postoperative period. By adapting available techniques to prioritize patient safety, general anesthesia with preserved spontaneous ventilation proved to be a viable and effective alternative when conventional approaches posed a significant risk. This strategy may be a safe option for similar patients undergoing open abdominal procedures.
Meireles et al. (2026) studied this question.