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CASE REPORT
Year : 2008  |  Volume : 52  |  Issue : 5  |  Page : 569 Table of Contents     

Successful Resuscitation in Accidental Complete Transection of Superior Vena Cava During Right Pleuropneumonectomy


1 Consultant, Department of Anaesthesiology, Jaslok Hospital and Research Centre, India
2 Registrar, Department of Anaesthesiology, Jaslok Hospital and Research Centre, India

Date of Acceptance30-Apr-2008
Date of Web Publication19-Mar-2010

Correspondence Address:
Rajashree Agaskar
Department of Anaesthesiology, Jaslok Hospital and Research Centre, 15 Dr. G. Deshmukh Marg, Mumbai 400 026, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


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This is a case report of complete transection of superior vena cava (SVC) during right pleuropn­eumonectomy leading to circulatory collapse and loss of venous access. Access was reestablished by imm­ediate cannulation of saphenous vein in the lower extremity. The patient was resuscitated with intravenous (IV) vasopressin followed by volume replacement. The patient tolerated 40 min of simple SVC clamping in spite of associated severe hypotension.

Keywords: Surgery, Extrapleural pneumonectomy or pleuropneumonectomy, Complication: Superior venacava transection/ clamping, Vasopressin


How to cite this article:
Agaskar R, Goswami J, Bartarya S. Successful Resuscitation in Accidental Complete Transection of Superior Vena Cava During Right Pleuropneumonectomy. Indian J Anaesth 2008;52:569

How to cite this URL:
Agaskar R, Goswami J, Bartarya S. Successful Resuscitation in Accidental Complete Transection of Superior Vena Cava During Right Pleuropneumonectomy. Indian J Anaesth [serial online] 2008 [cited 2019 Dec 12];52:569. Available from: http://www.ijaweb.org/text.asp?2008/52/5/569/60677


   Introduction Top


Extrapleural pneumonectomy (EPP) or pleuropneumonectomy for diffuse malignant mesothe­lioma of pleura is a radical procedure which in­volves en bloc resection of the pleura, lung, ipsilat­eral hemidiaphragm and anterior pericardium [1] . We report an extremely rare catastrophic complication, which occurred during right pleuropneumonectomy. There was complete transection of superior vena cava (SVC) leading to circulatory collapse and loss of venous access. The patient was resusci­tated with intravenous (IV) vasopressin followed by volume replacement. The patient tolerated 40 min of simple SVC clamping in spite of associated severe hypotension.


   Case report Top


A 34-year-old, 57- Kg male, a case of ma­lignant pleural epithelial mesothelioma was scheduled for right pleuropneumonectomy after three cycles of chemotherapy. On examination, remark­able findings were heart rate (HR) 128/min and decreased air entry on right side of the chest. Laboratory investigations were remarkable for hae­moglobin (Hb) 8.26 g.dL -1 , haematocrit (Hct) 29.5 % and platelet count 555 K/mL. Two dimensional echocardiography of the heart was unremarkable. Chest X-ray showed right pleural based opacity [Figure 1]. Computed tomography (CT) scan of chest was reported as - "…marked thickening of the right pleura with nodular mass lesion along the costal and mediastinal surfaces,…encasement of right main bronchus,…mediastinal vascular struc­tures are unremarkable" [Figure 2]. Pulmonary func­tion tests showed moderate restrictive defect. Pre­dicted FEV 1 after pneumonectomy was 1.63 L. In the operation theatre, peripheral venous access was established in right forearm. Monitoring in­cluded SpO 2 , ECG, end-tidal CO 2 , CVP through right internal jugular vein and intra-arterial pressure through left radial artery. General anaesthesia was induced with morphine 10mg/ midazolam 1mg/ propofol 140mg/ atracurium 50mg IV. Trachea was intubated with 9mm single lumen cuffed endotra­cheal tube. Anaesthesia was maintained with isoflurane/ nitrous oxide/ oxygen.

The patient was positioned in left lateral decubitus. The patient remained haemodynamically stable till removal of the specimen. During this phase of 2.5 h, blood loss was approximately 2.5 L. The patient was transfused with 7 units blood, 1 L Ringer's lactate and 500 mL gelofusine. After removal of the specimen, arterial pressure contin­ued to decrease in spite of rapid transfusion of blood and cause was found to be complete transec­tion of SVC just above the right atrium (RA). Intravenous infusions were only flooding the surgi­cal field and were therefore stopped. At this point, the vital parameters were mean arterial pressure (MAP) 19 mmHg, HR 110/min and EtCO 2 7mmHg. Two severed ends of SVC were immedi­ately clamped. With this, vital parameters improved to MAP 32 mmHg, HR 119/min and EtCO 2 9-11 mmHg. At this critical juncture, we could manage to re-establish intravenous access in right saphen­ous vein. Mephentermine 15 mg (IV) was given to which there was no response. Vasopressin 40 U (IV) was given thereafter. MAP immediately in­creased to 72 (83/66) mmHg with HR 126/min and EtCO 2 21 mmHg. By this time, 20 min had elapsed since clamping of SVC. Cardiovascular surgeon was summoned by operating oncosurgeon. To aid venous drainage, internal shunt was inserted from SVC to RA. Total SVC clamp time was 40 min. RA line was established for RA pressure monitoring. SVC was reconstructed with 7 cm long Gore-Tex graft [Figure 3]. Arterial blood gas analysis, 50 min after the complication showed Hb 6 g/dL and Hct 19 % but no metabolic acidosis. After about 90 min post-complication, CVP in­creased to 18-20 mmHg, with systolic BP 90-100 mmHg. CVP decreased to 7-8 mmHg after 40 mg frusemide and dopamine 5 mcg.Kg -1 .min -1 . Dura­tion of second phase from removal of the speci­men to the end of the operation was 2.5 h, during which the patient received 1 L Ringer lactate, 7 units blood, 9 units fresh frozen plasma, 6 units platelets, and 8 mg dexamethasone. Estimated blood loss during the surgery was 5.5 L. At the end of the operation, the patient was opening eyes to commands. Trachea was extubated after 4 days of elective ventilation. On postoperative day 6, aspirin and clopidogrel were started. The patient recovered without any neurological deficit or renal dysfunction. The patient was discharged on post­operative day 21.


   Discussion Top


EPP is a challenging operation associated with perioperative morbidity of 60-63% [2],[3] . SVC is a middle mediastinal structure vulnerable to invasion from tumors of anterior mediastinum and right up­per lobe of the lung. We failed as a team to anticipate possible injury to SVC due to its prox­imity to tumor. Problems we faced due to SVC transection, were not only loss of significant blood volume but also the route of volume administration. Prompt clamping of SVC followed by vasopressin administration was lifesaving. Da Valle et al in 1986 reported 3 perioperative deaths out of 33 patients of EPP. One of these 3 deaths was related to bleeding as the tumor could not be resected due to extensive invasion of SVC [4] .

Haemorrhagic shock causes biphasic changes invasopressin concentration. In early shock, increased concentration is produced to maintain organ perfu­sion. As shock progresses, plasma concentration of vasopressin decreases [5]. At this stage we probably provided it exogenously resulting in dramatic hemo­dynamic response. Clamping of SVC causes de­crease in preload and possible cerebral venous congestion. Simple clamping of SVC can be well tolerated in most patients for more than 30 min without neurological deficit, provided there is no associated hypotension [6],[7],[8] . Our patient tolerated clamping for 40 min in spite of associated severe hypovolemia and hypotension. SVC bypass is recommended whenever technically possible to mini­mize the risk of cerebral venous congestion before clamping [9],[10]. Nakahara and colleagues advocated selecting patients for shunting on the basis of sub­clavian venous pressure more than 40 cm of H 2 O [7] . Gonzalez-Fajardo J A et al (1994) concluded from a study on 12 mongrel dogs that, shunting of blood is important in cases of nonobstructed SVC because the clamping produces hemodynamic com­promise and brain damage [11] . Internal shunt be­tween RA and SVC was inserted in our patient before reconstruction. In conclusion, catastrophic complication like transection of SVC can occur during right EPP. We recommend additional vascu­lar access in lower limb in patients undergoing right EPP. We also recommend early use of vasopressin as adjunct to volume resuscitation in sudden mas­sive intraoperative hemorrhage.

Preoperative interaction among the radiologist, surgeon and anaesthesiologist will help in anticipa­tion of such catastrotrophic complications during EPP.

 
   References Top

1.Rusch VW. Diffuse malignant mesothelioma. In: Shields T W, ed. General Thoracic Surgery. 5th ed. Philadelphia, Lippincott Williams and Wilkins 2000:767-82.  Back to cited text no. 1      
2.Sugarbaker DJ, Jaklitsch MT, Bueno R, et al. Preven­tion, early detection, and management of complica­tions after 328 consecutive extrapleural pneumonec­tomies. J Thorac Cardiovasc Surg 2004; 128:138-46.  Back to cited text no. 2  [PUBMED]  [FULLTEXT]  
3.Stewart DJ, Martin-Ucar AE, et al. Extrapleural pneu­monectomy for malignant pleural mesothelioma:the risks of induction therapy, right sided procedures and prolonged operations. Eur J Cardiothorac Surg 2005; 27:373-8.  Back to cited text no. 3  [PUBMED]  [FULLTEXT]  
4.Da Valle MJ, Faber LP, et al. Extrapleural pneumonec­tomy for diffuse malignant mesothelioma. Ann Thorac Surg 1986;42:612-8.  Back to cited text no. 4      
5.Kam PCA, Williams S, Yoong FFY. Review article - Vasopressin and terlipressin: pharmacology and its clinical relevance. Anaesthesia 2004;59:993-1001.  Back to cited text no. 5      
6.Masuda H, Ogawa T, et al. Total replacement of superior vena cava because of invasive thymoma: 7yrs' survival. J Thorac Cardiovasc Surg 1988; 95:1083. (Letter to the editor)  Back to cited text no. 6      
7.Nakahara K, Ohna K, et al. Extended operation for lung cancer invading the aortic arch and superior vena cava. J Thorac Cardiovasc Surg 1989;97:428-33.  Back to cited text no. 7      
8.Dartevelle PG, Chapeliar AR, et al. Long term follow­up after prosthetic replacement of superior vena cava combined with resection of mediastinal-pulmo­nary malignant tumors. J Thorac Cardiovasc Surg 1991;102:259-65.  Back to cited text no. 8      
9.Yoshimura H, Kazama S, et al. Lung cancer involving the superior vena cava: pneumonectomy with con­ comitant partial resection of superior vena cava. J Thorac Cardiovasc Surg 1979;77:83-86.  Back to cited text no. 9  [PUBMED]    
10.Piccione W, Faber LP, Warren WH. Superior vena caval reconstruction using autologus pericardium. Ann Thorac Surg 1990;50:417-9.  Back to cited text no. 10      
11.Gonzalez-Fajardo JA, Garcia-Yuste M, et al. Hemody­namic and cerebral repercussions arising from surgi­cal interruption of the SVC-Experimental model. J Thorac Cardiovasc Surg 1994;107:1044-49.  Back to cited text no. 11      


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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