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. - 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)