Perioperative management of a patient with polycythemia who developed massive hemorrhage

A 34-year-old man, 170 cm in height and 70 kg in weight, was scheduled for emergency operation because of gastric perforation due to gastric cancer under general anesthesia. His preoperative blood analysis showed 5.2 x 10(3) mm(-3) of red blood cell, 18 g x dl(-1) of hemoglobin and 48% of hematocrit. Based on this and other data, he was diagnosed as having polycythemia caused by stress. Anesthesia was induced with thiopental and maintained with O2-N2O-sevoflurane. The intraoperative blood loss reached approximately 7,000 ml. Although we administered only 4 units of fresh-frozen plasma (FFP) and 9,150 ml of fluid with no red cell concentrated, his hemodynamic state was stable during surgery. After the surgery, we administered the minimum amount of FFP according to his blood analysis. Although red cell concentrated was not administered in the perioperative period, his general condition remained stable.     

Successful anesthetic management of a postpartum patient with amniotic fluid embolism

We report a case of amniotic fluid embolism (AFE) after cesarean section (C/S). A 35-year-old primigravida with placenta previa and myoma underwent C/S because of nonreassuring fetal status caused by medical induction of labor. C/S was performed smoothly under general anesthesia and the baby had no problems. Immediately after the end of C/S, she went into sudden cardiovascular collapse and massive postpartum hemorrhage (PPH) became apparent. The mechanical ventilation with 100% oxygen was continued. Cardiovascular stabilization was attained with immediate administration of noradrenaline and blood transfusion. As her clinical course indicated coagulopathy due to disseminated intravascular coagulation (DIC), we gave transfusion of fresh frozen plasma and red cell concentrate before the diagnosis of DIC was established by laboratory tests. Since we thought that manual pressure and uterotonics were not adequate to stop PPH, we performed uterine artery embolization additionally. The PPH with DIC was stopped by these measures seven hours after C/S. The patient and her baby left the hospital with no complications. AFE is a rare and often fatal obstetric condition, characterized by sudden cardiovascular collapse, and massive bleeding with DIC. The prompt awareness and initiation of appropriate measures are mandatory for patient's survival.     

Anesthetic management of a patient with lymphangioleiomyomatosis who developed respiratory failure post-operatively

A 34-year old female underwent lung biopsy under video assisted thoracoscopic surgery for lymphangioleiomyomatosis (LAM). She had obstructive lung disease, and had a large amount of ascites. We did not treat her lung disease pre-operatively because her pulmonary symptom was not severe. During operation, anesthesia was uneventful even during one lung ventilation period. After surgery, she showed hypoxemia and fell into respiratory failure. We suspect that respiratory failure was induced by ascites in this case. Respiratory failure would have come from restrictive ventilatory impairment caused by a large amount of ascites in addition to the obstructive ventilatory impairment. Care should be taken on respiratory function in case of LAM with ascites during perioperative period.     

Survival after intraoperative pulmonary embolism of a patient with left adrenal tumor

We report a case of severe shock associated with intraoperative pulmonary embolism (PE). A 15-year-old girl was scheduled to undergo left adrenalectomy and removal of vena cava tumor thrombi. She had suffered from preoperative PE and a temporary IVC filter had been inserted. After left adrenalectomy and removal of vena cava tumor thrombi, IVC was declamped. Forty-five minutes after IVC declamping, circulatory collapse developed with severe hypoxia. Transesophageal echocardiography (TEE) revealed right ventricular dysfunction. We diagnosed PE and immediately started cardiopulmonary resuscitation. Ten minutes later, a stable cardio-respiratory condition was reestablished. TEE findings showed the restoration of right ventricular function. She recovered without any neurological complications. TEE may be useful for diagnosis of acute PE by secondary signs of pulmonary artery obstruction. When intraoperative PE is suspected, TEE should be used for early diagnoss of PE and monitoring cardiac function. This case also suggests that cardiopulmonary resuscitation maneuvers may ameliorate PE itself.     

Successful management of a patient with pulmonary arteriovenous fistula using a continuous intra-arterial blood gas monitoring system]

We successfully anesthetized a patient with pulmonary arteriovenous fistula who received partial pulmonary resection and pulmonary arteriovenous plastic operation under one lung ventilation anesthesia, using a continuous intra-arterial blood gas monitoring system. During anesthesia including one lung ventilation, the patient did not experience any fatal hypoxemia. The continuous intra-arterial blood gas monitoring system was useful in a patient with pulmonary arteriovenous fistula under one lung ventilation anesthesia.     

Successful management of fulminant pulmonary embolism using a novel portable extracorporeal life support system

A 46-year-old man presented to the emergency room with pain in his left leg, dyspnea, and general cyanosis. During examination he collapsed and required resuscitation. Under suspicion of pulmonary embolism, a new portable "click 'n run" extracorporeal life support system (LIFEBRIDGE-B(2)T [Medizintechnik AG, Ampfing, Germany]) was implanted by the femoral vessels under resuscitation within 15 minutes of presentation. The patient was stabilized, despite severe decompensation (pH, 6.8), and could be transferred for a computed tomographic scan, which confirmed massive pulmonary embolism. Still connected to the life support system, the patient was transferred to the operating room. After a pulmonary thrombectomy was performed, the patient recovered without any organ dysfunction. A portable emergency extracorporeal life support may change clinical practice in the treatment of patients with severe hemodynamic deterioration at emergency care hospitals.     

Fatal intra-operative pulmonary embolism following application of an Esmarch bandage

The objective of this paper is to raise the awareness of a possible fatal complication during operations in the lower limbs, when an Esmarch bandage is used for exsanguination of the affected limb during the operation. After reviewing the literature, four cases of fatal massive pulmonary embolism have been identified after Esmarch bandage application in trauma patients [Acta Anaesthesiol Belg 50(2) (1999) 95, Reg. Anaesth 6 (1983) 83, Anesthesiology 58 (1983) 373, Anaesthesia 25(3) (1970) 445] but there is no any reference to an elective case. The authors would like to report two cases of fatal embolism after Esmarch bandage application for both elective surgery (total knee replacement) and trauma (trimalleolar fracture). Both patients had received regional anaesthesia. After comparing the data from our cases and the literature, it is recommended that the Esmarch bandage should not be used in trauma, especially when there has been a delay in time for surgery. In elective cases of the lower limbs, preoperative cardiovascular evaluation and the exclusion of other factors predisposing to DVT are necessary, especially for patients more than 50 years old.     

Successful management of acute pulmonary embolism after surgery for lung cancer.

OBJECTIVE: Although many case reports of acute pulmonary embolism (APE) have been published, the literature dealing with the management of APE after resection of lung cancer is limited. This report describes seven cases of successful management of APE after surgery for lung cancer and discusses how to manage this problematic complication. METHODS: The medical charts of seven patients with APE after lobectomy and complete mediastinal lymphnode dissection were retrospectively reviewed. RESULTS: Six patients collapsed during their first attempt at walking after surgery in conjunction with a dramatic respiratory change. All these patients promptly underwent enhanced spiral computed tomography (CT) scanning. Bilateral clots were detected in all patients and one patient with a deep venous thrombus (DVT) in the femoral vein had a temporary inferior vena cava filter implanted. Non-surgical therapy was used for six patients: thrombolysis (systemic urokinase) and anticoagulant (heparin or argatroban) for four patients and only anticoagulant therapy started on the day after the operation using argatroban for two. There were no bleeding problems with these thrombolysis and/or anticoagulant therapies except in one case of hemorrhage induced by heparin usage on the day after the operation. None of the cases required allotransfusion in connection with these therapies. Thromboembolectomy was performed for one patient who was hemodynamically unstable due to massive embolism and primary atrial fibrillation. All patients were discharged from our hospital without major complications. CONCLUSIONS: Patients with pulmonary embolism after surgery for lung cancer can be treated aggressively with anticoagulants with/without fibrinolitics or even with pulmonary embolectomy on cardiopulmonary bypass, without excessive risk of bleeding complications. Enhanced spiral CT scanning was very helpful for making a simultaneous diagnosis of APE and DVT. The use of argatroban in conjunction with activated clotting time monitoring should be effective without causing bleeding problems during the early stages after pulmonary resection for lung cancer.     

Successful recovery from a massive pulmonary artery tumor embolism occurring during surgery for renal cell carcinoma

We report herein on a case of renal cell carcinoma with retrohepatic inferior vena cava tumor thrombus in which intraoperative cardiac arrest from a massive pulmonary embolism was managed successfully with emergency sternotomy and cardiopulmonary bypass, followed by the removal of the primary site and pulmonary artery embolus.     

Successful resuscitation of a patient who developed cardiac arrest from pulsed saline bacitracin lavage during thoracic laminectomy and fusion

A patient with a history of T12 burst fracture caused by a fall, and with progressive weakness and sensory loss in the left leg, survived a cardiac arrest after pulsed saline bacitracin lavage irrigation during a posterior spinal fusion.     

Successful thrombolysis for massive pulmonary embolism after pulmonary resection

We report the successful use of thrombolysis for acute massive pulmonary embolism 2 days after right lower lobectomy for bronchial adenocarcinoma. Pulmonary angiography revealed extensive clot unsuitable for surgical embolectomy. A bolus infusion of recombinant tissue plasminogen activator produced an immediate improvement in the patient’s hemodynamic state. There was substantial blood loss requiring the transfusion of 21 units of blood over the postoperative period. The patient made a successful recovery and remained well at 1 year.     

A patient with possible TRALI who developed pulmonary hypertensive crisis and acute pulmonary edema during cardiac surgery

There are very few case reports of transfusion-related acute lung injury (TRALI) under close hemodynamic monitoring. We encountered a case of possible TRALI during on-pump coronary artery bypass grafting (CABG). A 66-year-old man who had undergone on-pump CABG was administered fresh frozen plasma (FFP). One hour after FFP transfusion, pulmonary hypertensive crisis and subsequent hypoxic decompensation occurred. A second cardiopulmonary bypass (CPB) was needed for circulatory and respiratory deterioration. Extracorporeal life support (ECLS), intraaortic balloon pumping (IABP), and nitric oxide therapy were required after the surgery. Despite the severity of the initial state, his recovery was comparatively smooth. ECLS and IABP were removed on postoperative day (POD)1; the patient was extubated and discharged from the ICU on POD7 and POD12, respectively. The diagnosis of TRALI was confirmed by human leukocyte antigen antibody detection in the administered FFP. In addition, lymphocytic immunofluorescence test showed that a cross-match of the plasma from the pooled FFP against the recipient leukocytes was positive. The clinical course of the pulmonary artery hypertension was followed by a decrease in dynamic lung compliance. The mechanism of this phenomenon is unclear. However, it might suggest the possibility of vasoconstriction or obstruction of the peripheral pulmonary artery preceding lung damage, as in the case in animal models reported previously.