Cardiac Arrest Requiring CPB During Adrenalectomy And Cavoatrial Thrombectomy
Medically Challenging Case Report Poster
Anesthetic management of patients presenting for cavoatrial thrombectomy presents several challenges, this case describes the additional challenge of an occult bleed during IVC cross clamping. A 34 year old male with no significant past medical history was found to have a 15cm non-functional right adrenal mass with hepatic invasion and a cavoatrial tumor thrombus. The patient presented to the OR for an open right adrenalectomy, right nephrectomy, partial right hepatectomy, and IVC thrombectomy under general anesthesia. After induction and endotracheal intubation, an arterial catheter was placed in the radial artery and a 9fr double lumen catheter was placed in the right internal jugular vein. A TEE probe was placed which confirmed the thrombus extension into the right atrium. The patient underwent right adrenalectomy, nephrectomy and partial hepatectomy uneventfully. After IVC cross clamping for cavoatrial thrombectomy and repair, the patient developed expected hypotension requiring fluid resuscitation and vasopressor support. However, during the course of thrombectomy, vasopressor requirements continued to escalate. The patient was positioned in steep reverse trendelenburg and no obvious source of hemmorrhage was recognized. The patient continued to deteriorate and went into PEA arrest requiring emergent sternotomy and cardiopulmonary bypass with deep hypothermic arrest. TEE revealed global hypokinesis and volume depletion. An occult bleed was discovered once the patient was positioned supine, he was resuscitated with blood products and was weaned off bypass on minimal vasopressor support. The patient remained intubated and was transferred to the surgical ICU. Postoperative course was complicated by atrial fibrillation, renal failure and pericarditis, however the patient remained neurologically intact and was eventually discharged to rehabilitation. Final pathology revealed extraskeletal ewing's sarcoma.
Enter up to two references.
|1.||Morita Y, Ayabe K, Nurok M, et al. Perioperative anesthetic management for renal cell carcinoma with vena caval thrombus extending into the right atrium: case series. J Clin Anesth. 2017;36:39–46.|