A 57-Year-Old Man Undergoes Bronchoscopy for a Persistent Cough Productive

A 57-year-old man undergoes bronchoscopy for a persistent cough productive of blood-tinged sputum.  He denies chest pain, shortness of breath, wheezing, and weight loss.  He is a long-term cigarette smoker.  He is allergic to peanuts and shell fish.  A physical examination does not reveal any significant abnormalities.  He is sedated with fentanyl and midazolam, and a local anesthetic is applied.  The bronchoscope is subsequently introduced into the trachea without difficulty.  About 10 minutes into the procedure, he is noted to be cyanotic by the medical assistant.  The procedure is aborted and supplemental oxygen is administered.
His blood pressure is 112/78 mm Hg, pulse is 115/min, and respiratory rate is 20/min.  Pulse oximetry has fallen from 94% pre-procedure to 85% at present.  There is central cyanosis.  Vesicular breath sounds are heard bilaterally.  Myoclonic jerks involving all extremities are apparent.  There is no skin rash.
Immediate arterial blood gas analysis shows the following:

Which of the following is the most likely diagnosis?

A) Acute lung injury
B) Air embolism
C) Anaphylactoid reaction
D) Methemoglobinemia
E) Opioid (fentanyl) overdose

Correct Answer:

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