Asystole following positive pressure insufflation of right pleural cavity: a case report
Journal of Medical Case Reports
Asystole following positive pressure insufflation of right pleural cavity: a case report
Kari M Forde-Thielen 0
Mojca R Konia 0
0 Department of Anesthesiology, University of Minnesota , Box 294, B515 Mayo Memorial Building, 420 Delaware Street, SE, Minneapolis, MN 55455 , USA
Introduction: Adverse hemodynamic effects with severe bradycardia have been previously reported during positive pressure insufflation of the right thoracic cavity in humans. To the best of our knowledge, this is the first report of asystole during thoracoscopic surgery with positive pressure insufflation. Case presentation: A 63-year-old Caucasian woman developed asystole at the onset of positive pressure insufflation of her right hemithorax during a thoracoscopic single-lung ventilation procedure. Immediate deflation of pleural cavity, intravenous glycopyrrolate and atropine administration returned her heart rhythm to normal sinus rhythm. The surgery proceeded in the absence of positive pressure insufflation without any further complications. Conclusions: We discuss the proposed mechanisms of hemodynamic instability with positive pressure thoracic insufflation, and anesthetic and insufflation techniques that decrease the likelihood of adverse hemodynamic events.
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Introduction
Hemodynamic consequences of pleural cavity positive
pressure insufflation during thoracoscopic procedures
have been described in the literature. While some of
these reports show minimal clinically significant effects,
others show serious hemodynamic consequences. One
potentially severe complication, asystole, has not
previously been reported. We present the case of a female
patient who underwent right thoracoscopic mediastinal
lymph node dissection with one-lung ventilation and
developed hypotension and asystole at the
commencement of positive pressure insufflation of her right
hemithorax. We discuss the proposed mechanisms for the
development of hemodynamic changes and asystole as
well as ways in which the safety of thoracoscopic surgery
can be improved.
Case presentation
A 63-year-old Caucasian woman with subcarinal and left
hilar lymphadenopathy presented to our hospital for a
right thoracoscopic mediastinal lymph node dissection.
Our patient had a history of endometrial adenocarcinoma,
and lymphadenopathy was noted on a follow-up
computed tomography scan. At the time of the initial
presentation, three years ago, the carcinoma was treated
surgically. The post-surgical course at that time was
complicated with deep vein thrombosis and pulmonary
embolism, which were treated with anticoagulation therapy and
the placement of an inferior vena cava filter. Our patient
denied any residual shortness of breath or limitation of
activity. She was participating in water aerobics and was
able to walk up a flight of stairs easily without shortness of
breath. Her history was also significant for
gastroesophageal reflux disease and dyslipidemia. Our patients
medications included ranitidine and simvastatin. She did not
report any allergies. A physical exam was unremarkable
except for obesity (weight 119 kg; height 165 cm).
Standard American Society of Anesthesiologists (ASA)
monitors were placed. After a rapid sequence induction
(fentanyl 1 g/kg, lidocaine 1 mg/kg, propofol 2 mg/kg,
succinylcholine 1.5 mg/kg) our patient was intubated with
a 39 French left-sided double lumen endotracheal tube.
Anesthesia was maintained with desflurane 5-6%, fentanyl
(total intraoperative dose 300 g), vecuronium 4 mg and
fraction of inspired oxygen (FiO2) at 1.0. Our patient was
turned to the left lateral position and the correct position
of the endotracheal tube was confirmed with fiberoptic
bronchoscopy. Left sided one-lung ventilation was
initiated (tidal volume 300cc, respiratory rate 16/min,
positive-pressure respiration (PEEP) 4, FiO2 1.0). Incisions
were made soon after initiation of one-lung ventilation,
and ports were inserted. Vitals signs at the time of incision
included saturated oxygen 99-100%, noninvasive blood
pressure 150/75 mmHg and pulse 80/min. Her right
hemithorax was insufflated with carbon dioxide to a pressure of
10 mmHg at a rate of 25 L/min. At this point in the
procedure we noted changes in our patients hemodynamic
status. Her blood pressure dropped to 112/63 and her heart
rate precipitously dropped to 35/min for a few seconds.
This was followed by asystole. The surgeon was notified,
insufflation was stopped and glycopyrrolate 0.4 mg and
atropine 0.4 mg were administered. Within 10 seconds of
pleural deflation our patient resumed a normal sinus
rhythm. Her next blood pressure reading was 125/75. In
the absence of further rhythm or hemodynamic
abnormalities the surgery was continued. The pleural cavity was
slowly insufflated to a pressure of 8 mmHg and the case
progressed without any further complications. Our patient
had an uncomplicated post-operative course.
Discussion
Insufflation of the pleural cavity with carbon dioxide is
b (...truncated)