LETTER TO EDITOR
Year : 2015 | Volume
| Issue : 1 | Page : 101-102
Cardiopulmonary bypass with deep hypothermic circulatory arrest for liver abscess with inferior vena cava thrombus: An anesthetic challenge
Nita Hazarika, Ramesh Kashav, Rajesh Sood
Department of Anesthesia, PGIMER and Dr. Ram Manohar Lohia Hospital, New Delhi, India
Dr. Nita Hazarika
Dr. Ram Manohar Lohia Hospital, R-712, 2nd Floor, New Rajinder Nagar, New Delhi
Source of Support: None, Conflict of Interest: None
|Date of Web Publication||5-Dec-2014|
|How to cite this article:|
Hazarika N, Kashav R, Sood R. Cardiopulmonary bypass with deep hypothermic circulatory arrest for liver abscess with inferior vena cava thrombus: An anesthetic challenge. Saudi J Anaesth 2015;9:101-2
|How to cite this URL:|
Hazarika N, Kashav R, Sood R. Cardiopulmonary bypass with deep hypothermic circulatory arrest for liver abscess with inferior vena cava thrombus: An anesthetic challenge. Saudi J Anaesth [serial online] 2015 [cited 2021 Dec 5];9:101-2. Available from: https://www.saudija.org/text.asp?2015/9/1/101/146332
Amoebic liver abscess (ALA) is a fairly common entity especially in developing countries but uncommon in the pediatric population. It can present in a myriad ways with various complications with significant morbidity and mortality. Inferior vena cava (IVC) and/or hepatic vein thrombosis are among them which are very rare and reported scarcely.  Surgical removal poses a challenge to both surgeons and anesthesiologist because of the complications involving surgical access, bleeding, massive blood transfusion, coagulation defect, pulmonary embolism, large fluid shifts, and significant postoperative complications. The common methods used to prevent pulmonary embolism are veno-venous bypass or cardiopulmonary bypass (CPB) with deep hypothermic circulatory arrest (DHCA).
A 5-year-old boy weighing 23 kg presented to our institute with high-grade fever for 15 days associated with distension of abdomen. The physical examination revealed a conscious average built child with heart rate 126/min, blood pressure 100/70 mmHg and respiratory rate 22/min. Abdominal examination revealed tender hepatomegaly and ascites. On auscultation, air entry was diminished on left side of the chest. His blood investigations showed Hb 9 g/dl, total leucocyte count of 20,000/mm 3 , elevated liver enzymes and an international normalised ratio of 2.1. Electrocardiogram (ECG) and chest X-ray was normal. Ultrasonography of the abdomen showed a large abscess closely abutting the intrahepatic vena cava. An echogenic lesion of 27 mm length extended from abscess to the IVC. Contrast-enhanced computed tomography of abdomen revealed left lobe liver abscess in segments II and III. The thrombus was visible in the middle and left hepatic veins together with a thrombus in the IVC which extended up to the right atrium (RA). A two-dimensional-echocardiography also confirmed the above findings as well as normal left ventricular function. Amoebic serology was positive. Considering the risk of pulmonary embolism, urgent surgery was planned with CPB for removal of the thrombus followed by laparotomy for drainage of the liver abscess.
During preanesthetic visit, a written informed consent was obtained and adequate blood and blood products were arranged. On the day of surgery, patient was shifted in the operating room. ECG, pulse oximetry, noninvasive blood pressure were attached.
Anesthesia was induced with fentanyl 2 mcg/kg, propofol 2 mg/kg and tracheal intubation with 5 mm internal diameter cuffed endotracheal tube was facilitated with vecuronium 0.1 mg/kg. The left internal jugular vein and left radial artery were cannulated under strict asepsis. CPB was established with aortocaval cannulation. After cooling to 20°C, cardioplegic arrest was achieved. Total circulatory arrest (TCA) was established. RA was opened followed by piecemeal extraction of the thrombus. CPB was weaned off after re-warming. Infusion dopamine was started at a rate of 5 mcg/kg/min, while separating the patient from the CPB. The duration of CPB and TCA were 68 min and 15 min respectively. This was followed by the laparotomy for drainage of the liver abscess and about 100 ml of anchovy sauce pus was drained from the abscess cavity. Surgery lasted for 3 h and the child was hemodynamically stable throughout. The dopamine drip was also discontinued towards the end of surgery and the child transferred to the Intensive Care Unit. He was extubated successfully after 6 h and was discharged from the hospital after 10 days. Anticoagulation with warfarin was started on the day following surgery and continued for 6 weeks. There was no recurrence of thrombosis or embolic events in the follow-up period.
Anesthetic management for surgical removal of ALA with thrombus in the IVC extending to RA is challenging due to high incidence of tumor thrombus migration, which may result in pulmonary embolism and cardiovascular collapse. Veno-venous bypass or CPB with DHCA are the ideal techniques as the surgery is done in a bloodless field. However, veno-venous bypass cannot be used in children of <10-15 kg because of the difficulty in maintaining adequate flow through the small cannulas.  Hence, we went for CPB with TCA in our patient.
Use of CPB and DHCA to facilitate the removal of thrombus associated with renal tumors is well-documented and advocated by several authors,  which can otherwise lead to fatal outcomes.  The development of CPB for repair of cardiac anomalies during the 1950s stimulated an appraisal of its potential in assisting with the management of other disease processes as well and today it has made the repair of vascular abnormalities such as intracranial aneurysms and the resection of tumors and thromboses of the vena cava/RA possible. The anesthetic considerations in the noncardiovascular applications of CPB are similar to those in cardiac surgery. CPB can cause adverse effects in the same organ systems whether it is used for cardiac surgery or noncardiac applications. This level of risk may be further increased when these organ systems are the focus of the operation. Although the incidence of cardiac complications should be lower in noncardiac surgeries with a healthy heart, if hypothermia and circulatory arrest are used or if the pump time is long, the risk for dysrhythmias and left ventricular dysfunction increases.  Personnel in the operating room involved in the surgical monitoring and anesthetic management must be well-versed and experienced in the implementation and use of CPB. 
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