|Year : 2008 | Volume
| Issue : 5 | Page : 569
Successful Resuscitation in Accidental Complete Transection of Superior Vena Cava During Right Pleuropneumonectomy
Rajashree Agaskar1, Jyotsna Goswami1, Shobhit Bartarya2
1 Consultant, Department of Anaesthesiology, Jaslok Hospital and Research Centre, India
2 Registrar, Department of Anaesthesiology, Jaslok Hospital and Research Centre, India
|Date of Acceptance||30-Apr-2008|
|Date of Web Publication||19-Mar-2010|
Department of Anaesthesiology, Jaslok Hospital and Research Centre, 15 Dr. G. Deshmukh Marg, Mumbai 400 026, Maharashtra
Source of Support: None, Conflict of Interest: None
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 2020 Jul 4];52:569. Available from: http://www.ijaweb.org/text.asp?2008/52/5/569/60677
| Introduction|| |
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  . 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|| |
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|| |
EPP is a challenging operation associated with perioperative morbidity of 60-63% , . 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  .
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 . 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 ,, . 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 ,. Nakahara and colleagues advocated selecting patients for shunting on the basis of subclavian venous pressure more than 40 cm of H 2 O  . 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  . 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|| |
|1.||Rusch VW. Diffuse malignant mesothelioma. In: Shields T W, ed. General Thoracic Surgery. 5th ed. Philadelphia, Lippincott Williams and Wilkins 2000:767-82. |
|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. [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. [PUBMED] [FULLTEXT] |
|4.||Da Valle MJ, Faber LP, et al. Extrapleural pneumonectomy for diffuse malignant mesothelioma. Ann Thorac Surg 1986;42:612-8. |
|5.||Kam PCA, Williams S, Yoong FFY. Review article - Vasopressin and terlipressin: pharmacology and its clinical relevance. Anaesthesia 2004;59:993-1001. |
|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) |
|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. |
|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. |
|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. [PUBMED] |
|10.||Piccione W, Faber LP, Warren WH. Superior vena caval reconstruction using autologus pericardium. Ann Thorac Surg 1990;50:417-9. |
|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. |
[Figure 1], [Figure 2], [Figure 3]