Glavna A & A Practice An Unusual Cause of Intraoperative Hemodynamic Instability Complicating Elective Mastectomy With...
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E CASE REPORT An Unusual Cause of Intraoperative Hemodynamic Instability Complicating Elective Mastectomy With Immediate Free Flap Reconstruction: A Case Report Bruce Young, FRCA, Christos Chamos, MD, DESA, Ben Fitzwilliams, FRCA, and Neel Desai, FRCA Extrinsic compression of the heart consequent to intrapleural fluid is a rare cause of cardiac tamponade. Cases of massive hemothorax resulting in external cardiac tamponade due to injury of the internal thoracic artery (ITA) following blunt or penetrating trauma have been described in the literature. Here, we present a case of iatrogenic injury to the right ITA complicating mastectomy and deep inferior epigastric perforator flap reconstruction. It manifested as hemodynamic instability that persisted despite aggressive fluid resuscitation. Investigation with an intraoperative transesophageal echocardiogram demonstrated cardiac tamponade secondary to a massive hemothorax which resolved following surgical placement of an intercostal drain. (A&A Practice. 2020;14:102–5.) Downloaded from http://journals.lww.com/aacr by BhDMf5ePHKbH4TTImqenVJrtsMDDBIGOyWaAmivM+XODiIS7HtvRCgVQRBGvrjFlCfIxzWKSerQ= on 04/09/2020 GLOSSARY CT = computed tomography; DIEP = deep inferior epigastric perforator; ITA = internal thoracic artery; LA = left atrium; LV = left ventricle; PF = pleural fluid; RA = right atrium; RV = right ventricle; TEE = transesophageal echocardiogram A cute cardiac tamponade is a life-threatening condition that necessitates immediate diagnosis and treatment.1 Extrinsic compression causes a progressive constriction of the heart chambers, impairing diastolic compliance and resulting in a reduction of end-diastolic and stroke volumes.2,3 Cardiac tamponade is most commonly secondary to an increase in intrapericardial pressure due to the accumulation of fluid, blood, pus, or air within the pericardium, but this is not the only mechanism.3 It can rarely occur secondary to large unilateral or bilateral pleural effusions even in the absence of pericardial fluid.; 4 This has been demonstrated in animal studies3 and described in patients with pleural effusions of various etiologies5–7 including cases of traumatic hemothoraces.8,9 Here, we present what the authors believe is the first reported case of an intraoperative external cardiac tamponade due to damage to the internal thoracic artery (ITA) and secondary massive hemothorax. Written consent for publication of this case report was obtained from the patient. CASE DESCRIPTION A 57-year-old woman with intermediate-grade ductal breast carcinoma in situ and multifocal grade 1 invasive cancer of the upper outer quadrant of the right breast presented for an elective right mastectomy with immediate From the Department of Anaesthetics, Guy’s and St Thomas’ NHS Foundation Trust, London, United Kingdom. Accepted for publication November 20, 2019. Funding: None. The authors declare no conflicts of interest. Address correspondence to Bruce Young, FRCA, Department of Anaesthetics, Guy’s and St Thomas’ NHS Foundation Trust, Westminster Bridge Rd, London, SE1 7EH, United Kingdom. Address e-mail to bruce. firstname.lastname@example.org. Copyright © 2019 International Anesthesia Research Society DOI: 10.1213/XAA.0000000000001157 102 cases-anesthesia-analgesia.org reconstruction using a deep inferior epigastric perforator (DIEP) free flap. Her background included hypertension, but there was no other significant anesthetic or medical history. She had a body mass index of 34 and her preoperative hemoglobin was 12.8 g/dL, with the rest of her blood panel found to be unremarkable. After establishing electrocardiographic, pulse oximetric, and noninvasive blood pressure monitoring, anesthesia was induced and maintained with total intravenous anesthesia using propofol and remifentanil, and a tracheal tube followed by an arterial line were inserted. Following transfer from the anesthetic room to the operating theater and patient positioning, surgery commenced uneventfully until completion of the right mastectomy. It was at this point that, while preparing the recipient vessels for the DIEP flap, an injury occurred to the ITA and pleura, giving rise to a brisk and large external bleed of approximately 1100 mL. The injury was repaired by the plastic surgeons within minutes and no further hemorrhage was visualized. In response to this, the patient became increasingly tachycardic and hypotensive with the highest heart rate and lowest blood pressure, respectively, recorded as 124 beats/min and 65/40 mm Hg. Fluid resuscitation was immediately started with 2000 mL of Hartmann solution, 4 units of packed red blood cells, and 4 units of fresh frozen plasma. Moreover, 1 g of tranexamic acid was administered. Subsequent to the first unit of packed red blood cells having been administered, an arterial blood gas demonstrated the hemoglobin to be 6.6 g/dL. Despite fluid resuscitation and support of cardiovascular parameters with metaraminol in divided doses of 0.5 mg, only transient hemodynamic improvement could initially be achieved with slowly recurring tachycardia and hypotension. Later, even though the post-transfusion arterial blood gas revealed a hemoglobin of 8.3 g/dL, lactate of 3.1 mmol/L, and negative base excess of 4.5, the hemodynamics of the patient no longer improved with fluid resuscitation and showed minimal response to February 15, 2020 • Volume 14 • Number 4 Copyright © 2019 International Anesthesia Research Society. Unauthorized reproduction of this article is prohibited. Figure 1. Images from an intraoperative transesophageal echocardiogram. Midesophageal 4-chamber view (A) and midesophageal view with clockwise probe rotation (B) demonstrating extrinsic compression and collapse of the right atrium (A) and a right pleural effusion (B). LA indicates left atrium; LV, left ventricle; PF, pleural fluid; RA, right atrium; RV, right ventricle. escalating doses of metaraminol either administered as a bolus or peripheral infusion. It was clear to the clinical team that, in the absence of continuing obvious bleeding, the patient was not responding in the expected manner to the management strategy that had been instituted hence far. In light of this, other concomitant diagnoses were considered, such as acute heart failure due to fluid overload, hemothorax, and pneumothorax. Of note, there had not been a decrease in the oxygen saturation or an increase in the airway peak pressure, and the trachea remained central with evidence of bilateral anterior air entry. The clinical team requested assistance from a cardiac anesthetist to perform an on-table transesophageal echocardiogram (TEE) in order to assess her left ventricular function. It demonstrated an underfilled left ventricle with no regional wall motion abnormalities, but the most striking finding was significant compression of the right atrium (Figure 1A). Furthermore, a large right intrathoracic fluid collection and a very small pericardial collection were shown (Figure 1B). These findings were in keeping with external cardiac tamponade secondary to a massive rightsided hemothorax. In view of this, after a preprocedural ultrasound scan performed by a radiologist, an intercostal drain insertion was performed by a cardiothoracic surgeon. Seven hundred milliliters of fresh blood was drained over the next 15 minutes, adequate to relieve extrinsic cardiac compression (Figure 2), and a rapid return of hemodynamic stability was observed, sufficient to facilitate discontinuation of peripheral vasopressors. It was at this time that the cardiothoracic surgeon was able to visually inspect the repair of the pleura and the ITA. Given that the DIEP flap had already been prepared earlier on in the operation and there were no signs of further bleeding, extrinsic cardiac compression, or hemodynamic instability, a multidisciplinary decision was made to complete the surgery. Unfortunately, her postoperative recovery was complicated by flap failure and she was reoperated on overnight for attempted salvage before eventual removal of the flap. February 15, 2020 • Volume 14 • Number 4 Figure 2. Midesophageal 4-chamber view from a transesophageal echocardiogram demonstrating relief of the cardiac tamponade after drainage of the right hemothorax. LA indicates left atrium; LV, left ventricle; RA, right atrium; RV, right ventricle. On the first day in the postoperative intensive recovery unit, a chest radiograph demonstrated a large and persistent collection within the right hemithorax (Figure 3). Further imaging with computed tomography of her chest showed a significant residual hemothorax (Figure 4A, B). This was treated by video-assisted thoracoscopic surgery where 1200 mL of residual liquid and clotted blood was washed out (Figure 5). Subsequent to tracheal extubation, removal of chest drains and a period of rehabilitation, she was discharged from hospital 11 days following the original operation. DISCUSSION Breast reconstruction with a DIEP flap necessitates the exposure and preparation of the recipient vessels. Due to their propensity for excellent flow of 15–35 mL/min and low rate of subsequent atheroma formation, the ITAs are commonly selected.10,11 Iatrogenic damage of the artery, pleura, or vein, however, are all potential complications. In the case described here, the ITA and pleural were simultaneously cases-anesthesia-analgesia.org 103 Copyright © 2019 International Anesthesia Research Society. Unauthorized reproduction of this article is prohibited. injured, providing the conditions required for the development of a massive hemothorax. Cardiac tamponade can be diagnosed by either clinical assessment or medical imaging alone or in combination.12 Clinical signs vary13 and the eponymous Beck triad of tachycardia, hypotension, and raised jugular venous pressure is found in only 10%–40% of patients.2 Pulsus paradoxus, defined as a decrease of >10 mm Hg in the systolic blood pressure during the inspiratory phase of respiration, is present in 77% of cases.2 It can be subtle in hypovolemia and may be absent or reversed, respectively, in left ventricular dysfunction and positive pressure ventilation.3,9 In general, a picture of increased sympathetic drive and progressive dyspnea is likely,2 but the latter cannot be evaluated in an anesthetized patient. As cardiac output falls, signs of decreased end-organ perfusion such as confusion, a progressive metabolic acidosis, and reduced urine output develop. In patients who are ventilated, as was the case here, hemodynamic compromise can present more readily as the negative intrapleural pressure generated during spontaneous inspiration is replaced by positive intrathoracic pressure, further reducing venous return.11 Diagnosis of external cardiac tamponade, caused by the pressure exerted by fluid in the pleural rather than pericardial space, can be more challenging. Published reports of Figure 3. Chest radiograph showing diffuse and increased opacification of the right hemithorax. The orange arrow indicates the intercostal drain and the white arrows point to the breast tissue expander. massive pleural effusions occurring due to cardiac failure or liver disease describe an insidious onset of respiratory symptoms preceding cardiovascular collapse.5 If external cardiac tamponade is a result of massive hemothorax, then cardiovascular compromise may occur early secondary to acute hemorrhage.8 Resuscitation with intravenous fluid and blood products to replenish the circulating volume can transiently increase cardiac output or, depending on the severity of cardiac tamponade, the patient may remain in fluid refractory hypotension. In this particular case, the presence of both obvious and occult bleeding made the diagnosis even more difficult for the clinical team to establish. Initial hemodynamic instability was thought to be due to hypovolemia, yet when it did not improve following the cessation of visible hemorrhage and appropriate resuscitation, the differential diagnosis was reconsidered, prompting the need for further investigation. Rescue echocardiography is a valuable modality in the assessment of persistent or unexplained hypotension. Operators can interrogate for hypovolemia, ventricular dysfunction, valvular pathology, signs consistent with pulmonary embolism, and pericardial or pleural effusion with or without signs of cardiac tamponade. If right atrial collapse is present, as was the case here, its persistence for over a third of the cardiac cycle has a 94% sensitivity and 100% specificity for cardiac tamponade.14,15 Should cardiac tamponade be found, it is sensible to image for a pleural effusion as there is otherwise a potential for inappropriate attempts at pericardiocentesis to be undertaken.4 Emergency treatment of external cardiac tamponade must include attempts to decrease intrathoracic pressure, most commonly achieved by the insertion of an intercostal drain. In our case, the initial intercostal drainage of blood was adequate to resolve intraoperative hemodynamic instability. It should be remembered, however, that each hemithorax will accommodate a large volume of blood before the pressure increases to the point of causing cardiac tamponade. In view of this, cardiothoracic review and imaging should be sought as soon as possible to confirm the complete drainage of any residual blood and the integrity of vascular repair to avoid subsequent complications. In conclusion, the intraoperative development of external cardiac tamponade secondary to hemothorax is rare in noncardiac surgery. If iatrogenic damage to intrathoracic Figures 4. Computed tomography (CT) of the chest showing a large right residual hemothorax with contralateral shift of the mediastinum. The orange arrow indicates the intercostal drain and the white arrows point to the breast tissue expander. 104 cases-anesthesia-analgesia.org A & A PRACTICE Copyright © 2019 International Anesthesia Research Society. Unauthorized reproduction of this article is prohibited. Figure 5. Chest radiograph showing decreased volume in the right hemithorax and a small residual pleural effusion following videoassisted thoracoscopic surgery. The orange arrows indicate the intercostal drains. vessels is a possible complication, the authors suggest that consideration should be given to external cardiac tamponade as a cause of refractory hemodynamic compromise. E DISCLOSURES Name: Bruce Young, FRCA. Contribution: This author helped prepare and write the manuscript. Name: Christos Chamos, MD, DESA. Contribution: This author helped revise the manuscript. Name: Ben Fitzwilliams, FRCA. Contribution: This author helped revise the manuscript. Name: Neel Desai, FRCA. Contribution: This author helped write and revise the manuscript. This manuscript was handled by: Kent H. Rehfeldt, MD. REFERENCES 1. Vaska K, Wann LS, Sagar K, Klopfenstein HS. Pleural effusion as a cause of right ventricular diastolic collapse. Circulation. 1992;86:609–617. February 15, 2020 • Volume 14 • Number 4 2. Ariyarajah V, Spodick DH. Cardiac tamponade revisited: a postmortem look at a cautionary case. Tex Heart Inst J. 2007;34:347–351. 3. Spodick DH. 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