anesth analg 2002 vaughn 1149 51

7/31/2019 Anesth Analg 2002 Vaughn 1149 51

1/3

CASE REPORTS

Massive Hemorrhage During Radiofrequency Ablation of a

Pulmonary Neoplasm

Cynthia Vaughn, MD, George Mychaskiw II, DO, and Patrick Sewell, MD

Departments of Anesthesiology and Radiology, University of Mississippi School of Medicine, Jackson

Radiofrequency energy has historically been usedfor electrocautery in surgery and as ablativetherapy of conduction pathways in conditions

such as Wolff-Parkinson-White syndrome and refrac-tory supraventricular tachycardia. Recently, the clini-cal uses of radiofrequency ablation have been ex-panded to include treatment of both hepatic andpulmonary neoplasms (1). We describe the anestheticmanagement of a patient who experienced intraoper-ative pulmonary hemorrhage while undergoing radio-frequency ablation of a primary lung tumor.

Case ReportA 70-yr-old man presented for radiofrequency ablation of anadenocarcinoma of the right lung measuring 2.5 3.5 cm.He had a history of bilateral lung lesions and had undergone

several courses of chemotherapy (Taxol and Carboplatin), aswell as one surgical wedge resection. His medical historywas significant for hypertension, atherosclerotic heart dis-ease, and benign prostatic hypotrophy. His medications in-cluded aspirin 81 mg/d, which was discontinued 1 wk

before admission, fluvastatin 20 mg/d, enalapril 20 mg/d,clopidogrel 75 mg/d, oxycodone controlled release tablets10 mg every 12 h, and tamsulosin 0.4 mg/d.

At the time of admission, the patient related a history ofeasy bruising. Physical examination was unremarkable.Chest radiogram was significant for a midleft lung mass andan upper right lung mass. Laboratory findings included ahematocrit of 45%, platelet count of 289,000, a partial throm-

boplastin time of 33.2 s, and a prothrombin time of 11.7 s. Nostudies of platelet function were performed.

On the day of the procedure, the patient underwent anuneventful induction of anesthesia with sodium thiopental4 mg/kg, fentanyl 1.8 g/kg, and vecuronium 0.1 mg/kg.His trachea was intubated with an 8.0-mm endotrachealtube without difficulty. Anesthesia was maintained withdesflurane 3%4%, 100% oxygen, and 50 g of fentanyl

boluses. The patient remained stable during positioning andinitial computed tomography (CT) scanning.

Approximately 2 h after the radiofrequency ablation be-gan, the patient suddenly had a decrease in arterial oxygensaturation to 84% followed by hypotension with a decreaseof systolic blood pressure to 79 mm Hg. The blood pressurewas restored to 150 mm Hg with 2 boluses of phenylephrine,100 g each, and a 400-mL bolus of lactated Ringers solu-tion, positive end-expiratory pressure of 10 cm, was appliedand ventilation controlled. Despite these measurements, ittook 5 min to restore the arterial oxygen saturation to 97%.

A CT scan performed at the anesthesiologists suggestionrevealed extensive hemorrhage into the right lung and rightpleural cavity (Fig. 1). The patient was transferred from theCT scanner to angiography so that emergency pulmonaryand bronchial arteriograms could be performed. The rightinternal jugular vein was cannulated, and a blood samplewas sent for type and cross-match. A fiberoptic examinationthrough the existing endotracheal tube revealed blood at thecarina, and a 39F double lumen endobronchial tube wasplaced to isolate the lungs.

The hemorrhage was both intraparenchymal and ex-trapleural, but the pulmonary and bronchial arteriograms

failed to identify a distinct source of bleeding. After com-pletion of the arteriograms, the patient was transferred tothe intensive care unit.

The patient remained intubated and mechanically venti-lated for several days after surgery because of difficultieswith oxygenation. During the first postoperative day, hishematocrit decreased from a preoperative value of 45% to31%. Platelets were not transfused, and the patient had nofurther hemorrhage. On postoperative Day 8, while stillintubated, the patient had a non-Q wave myocardial infarc-tion. He was finally extubated on postoperative Day 11.Eight days later, he suffered an episode of pulmonary aspi-ration, which eventually led to his death on postoperativeDay 23.

DiscussionRadiofrequency ablation is the use of radiofre-quency energy to thermally destroy living tissue.Today, its use has been expanded to include bulktissue ablation of hepatic and pulmonary neoplasms(1). Because many of these neoplasms are not ame-nable to curative surgical resection, radiofrequencyablation represents an important new addition tothe treatment armamentarium.

The energy for radiofrequency ablation is producedby a generator and is introduced into the tumor

Accepted for publication January 8, 2002.Address correspondence and reprint requests to George Mychaskiw

II, DO, Department of Anesthesiology, University of MississippiSchool of Medicine, 2500 North State St., Jackson, Mississippi 39216-4505. Address e-mail to [email protected].

2002 by the International Anesthesia Research Society0003-2999/02 Anesth Analg 2002;94:114951 1149


2/3


3/3

in some institutions. It detects and records the kineticchanges in a sample of whole blood as the clot forms,retracts, or lyses. The resultant coagulation profile istherefore a measure of clot kinetics (formation anddissolution) and of clot quality (the ability to perform

the work of hemostasis). The TEG

coagulation ana-lyzer is a global test of hemostatic dysfunction and isnot a specific test for platelet dysfunction (4 6). Al-though it can detect platelet dysfunction after anti-platelet drug therapy, the TEG coagulation analyzeris less sensitive than the PFA-100 for this purpose.

Radiofrequency ablation is a new approach to thetreatment of pulmonary neoplasms. Although the in-cidence of complications is small, the presentationmay be dramatic, as in this case. We would recom-mend that patients undergoing this procedure have alarge-bore IV cannula, an arterial cannula, and a cur-rent type/screen. In addition, there should be height-ened awareness of any potential for coagulopathy.Most of these patients have received chemotherapywith possible bone marrow suppression and throm-

bocytopenia. In addition, many of these patients areelderly or are chronic tobacco users with an increased

incidence of peripheral vascular disease. A carefulmedication history should be taken to determinewhether any medications have been prescribed thatmight adversely affect hemostasis, and an appropriatepreoperative evaluation should be performed. Finally,

as pneumothorax is the most prevalent complicationof the procedure, personnel involved in these casesshould be vigilant for the occurrence of pneumothoraxand prepared to treat it if required.

References1. Sewell P. Assessment of radiofrequency ablation of non-small

cell lung cancer with positron emission tomography (PET).J Radiol 2000;217:334 7.

2. Lind SE. The bleeding time does not predict surgical bleeding.Blood 1991;77:254752.

3. Eberhard M, Comp P, Gosselin R, et al. PFA-100: a new methodfor assessment of platelet dysfunction. Semin Thromb Hemost

1998;24:195202.4. DeGaetano G, Vermylen J. Effect of aspirin on the thromboelas-tograph of human blood. Thromb Diath Haemorr 1973;30:494 8.

5. Mallett SV, Platt M. Role of thromboelastography in bleedingdiatheses and regional anaesthesia. Lancet 1991;338:765 6.

6. Orlikowski CEP, Moodley J, Rocke DA. Thromboelastography inpregnant patients on low dose aspirin. Lancet 1991;338:1276 7.

ANESTH ANALG CASE REPORTS 11512002;94:114951

anesth analg 2002 vaughn 1149 51

Documents