Case Discussion - UM Anesthesiology

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A Case of Life-Threatening
Hypertensive Crisis during
Hepatic Radiofrequency Ablation
Raza Zaidi, MD
Satya Krishna Ramachandran, MD
Department of Anesthesiology
University of Michigan Hospitals
Case Background
• 55 year-old male
• Hepatitis C and hepatocellular carcinoma
• Laparoscopic hand-assisted RFA of liver mass
Patient History
• PMH
– HCV cirrhosis/HCC
– DM II
– Nephrolithiasis
– HTN
– HL
– GERD (poorly
controlled)
– Morbid obesity
– Chronic back pain
• PSH
– Lap liver resection
– Tonsillectomy
Anesthetic Hx: DL: Grade 2B view
Social Hx: Remote hx of IVDA
Family Hx: Diabetes, HTN
• Medications
– Glyburide
– Glucophage
– Insulin glargine
– Alprazolam
– Omeprazole
– ASA
– Norco
• Allergies
– Amlodipine –
headaches
– NSAIDs – ulcers
– Simvastatin –
diarrhea
Pre-op Studies
Lab Values:
14.5
90
4.7
43.7
136
4.8
105
26
14
0.7
108
AST 81 ALT 96 INR 1.0
• EKG: NSR
• Dobutamine Stress Echo: EF 65%. No
inducible ischemia. Grade 1 LV dysfunction
MRI
Lesion
Hepatic Segmental Anatomy
Traditional Surgical Viewpoint of Liver Anatomy and Definition of the
Couinaud Segments 3-D tutorials of the Division of Physiologic Imaging,
Dept. of Radiology, Univ. of Iowa
Hepatic Radiofrequency Thermal
Ablation
Di Benedetto et al. (2012) Journal of Laparoendoscopic & Advanced Surgical
Techniques
Hepatic RFA Advantages
• Minimal invasiveness
• Treatment modality for unresectable lesions
• Reduced cost/hospital stay1
• Potential for repeated treatment for local recurrence
1L.
Solbiati et al. European Journal of Ultrasound 13 (2011) 149–158
Physical Exam
•
•
•
•
Afebrile
BP 139/77
HR 94 BPM
O2 sat 95% on RA
• 5’6” 120 kg, BMI 42.7
• Airway Exam: Mallampati III w/ thick, obese neck
Anesthetic Plan
• GETA, RSI
• Arterial line for hemodynamic monitoring
• 2nd IV after induction
• T&S
Induction
• Midazolam, fentanyl, propofol, succinylcholine
• Atraumatic endotracheal intubation on 1st attempt
• Arterial line and16g IV placed
Arterial line placed
Intraoperative Course
Surgical incision
RFA started
Intraoperative Course
BP 300/135
RFA started
Differential Diagnosis
•
•
•
•
•
Mechanical/Systems Error
Inadequate depth of anesthesia
Surgical factors
Pharmacologic
Physiologic/Pathologic
Next Steps…
• Communication
• Increased inhalation agent
• Propofol/fentanyl boluses
• RFA aborted
• Labetalol given
Intraoperative Course
RFA aborted
Intraoperative Course
RFA restarted
Intraoperative Course
RFA restarted RFA aborted
Intraoperative Course
…Try, Try Again?
American Journal of Roentgenology (2003)
Imaging
AJR:181, August 2003
Imaging
AJR:181, August 2003
Patient’s MRI
Lesion
Adrenal Gland
Intraoperative Course
RFA restarted
Hypertensive Crisis
• Hypertensive emergency - severe elevations in BP
[>180/110 mm Hg] complicated by evidence of
impending or progressive target organ dysfunction*
• Hypertensive urgency - severe elevations in BP
without progressive target organ dysfunction.
*Sixth
Report of the Joint National Committee on Detection, Evaluation, and Treatment of High Blood
Pressure (JNC6) (Chobanian et al 2003a; JNC 1997)
Pathophysiology of Hypertensive
Crisis
Acute elevation
in blood
pressure
Endothelial
Injury
Further release
of vasoactive
substances
Ischemia
(Disruption of
autoregulation)
Deposition of
platelets and
fibrin
(necrosis)
Complications of Hypertensive Crisis
• Cardiovascular
• Neurologic
• Renal
Pharmacological Management of
Acute Intraoperative Hypertensive
Crisis
• Peripheral vasodilators
• β-adrenergic blockade
Overview of intravenous drugs for the
treatment of intraoperative hypertensive
emergencies
Van den Born, et al. Dutch Guideline for the Management of Hypertensive Crisis- 2010 revision. The
Netherlands Journal of Medicine
Postoperative Course
• Extubated awake after reassuring neuro
exam
• Serial neuro exams
• Uncomplicated postop course
Discharged home on POD #1
RFA Complications
• Thermal/Mechanical injury to
surrounding structures
– Bowel perforation
– Cholecystitis
– Bile duct stricture
– Portal vein thrombosis
– Adrenal gland injury  HTN crisis
Recommendations
• Consider arterial line for tumors near
the adrenal gland
• Potential of hypertensive crisis - a
contraindication for hepatic
radiofrequency ablation?
Lessons Learned
• Understand the surgical procedure
• Review the imaging
• Importance of communication/information
technology
Patient Follow-up
• “Patient appears to have tolerated therapeutic
intervention well with no residual cancer at the site of
previous intervention. Unfortunately, patient has
evidence of a new lesion concerning for recurrence.
We will plan to review his most recent imaging at our
upcoming Liver Tumor Board to make additional
recommendation regarding his care and potential
intervention in the future…”
Thank You
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