Anesth Analg 2006;103:463-464
© 2006 International Anesthesia Research Society
doi: 10.1213/01.ane.0000223672.30521.d8
GENERAL ARTICLES
Lung Isolation, One-Lung Ventilation, and Continuous Positive Airway Pressure with Air for Radiofrequency Ablation of Neoplastic Pulmonary Lesions
Beth A. Elliott, MD*,
Timothy B. Curry, MD, PhD*,
Thomas D. Atwell, MD
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Michael J. Brown, MD*, and
Steven H. Rose, MD*
From the Departments of *Anesthesiology and Radiology, Mayo Clinic College of Medicine, Rochester, Minnesota.
Address correspondence and reprint requests to Beth A. Elliott, MD, Mayo Clinic, 200 First Street SW, Rochester, MN 55905. Address e-mail to elliott.beth{at}mayo.edu.
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Abstract
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Radiofrequency ablation (RFA) is an emerging therapy that is increasingly being used for the treatment of many different types of tumors. RFA uses percutaneously placed image-guided probes to destroy tissues through localized heating. Injury to adjacent tissues with significant morbidity during RFA has been reported in the literature. We discuss our anesthetic management of patients undergoing RFA of lung tumors. Lung isolation, one-lung ventilation, and nondependent lung continuous positive airway pressure with air can be used to minimize damage to the heart and other important structures.
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Introduction
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Radiofrequency ablation (RFA) is an effective treatment for a variety of solid organ and pulmonary tumors and is performed by placing an electrode percutaneously into a tumor under image guidance. The resultant heat from electrode activation (>60°C) causes instantaneous cell destruction (1). Injury to adjacent tissues is a major concern during RFA, and bowel perforation, cholecystitis, bile duct stricture, and portal vein thrombosis have been reported after RFA of intraabdominal tumors (2–4). Fatal esophageal injury after ablation procedures for atrial fibrillation has also been reported (5). The potential for adjacent tissue injury and its systemic consequences makes a "quiet operating field" essential for safe and effective use of RFA. The anesthetic management of these procedures continues to evolve. We report two cases of anesthetic management using lung isolation, one-lung ventilation, and nondependent lung continuous positive airway pressure (CPAP) administration for RFA of pulmonary lesions.
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Case Reports
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Case 1
A 36-yr-old female with synovial cell carcinoma presented for RFA of a left lung metastatic lesion. The patient had a history of multiple pulmonary resections, including four thoracotomies for excision of metastatic lesions to the right lung.
After induction of general anesthesia, a 37F left-sided double-lumen endotracheal tube was placed. After lung isolation, Fio2 of the ventilated lung was increased to 96%. During RFA, concern was expressed regarding the close proximity of the probes to the pericardium because of progressive volume loss in the nonventilated lung. Consequently, the endobronchial lumen was unclamped and both lungs were ventilated with Fio2 = 21%. After adequate re-expansion of the operative lung was obtained, the endobronchial lumen was re-clamped, lung isolation was established, and the ablation proceeded uneventfully (Fig. 1).
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Figure 1. A 36-yr-old female with history of synovial cell sarcoma and enlarging nodule in the left lower lobe, presumed to represent a metastasis, presented for radiofrequency ablation (RFA). A, axial computed tomography imaging showed a 6-mm nodule in the left lower lobe (arrow). B, the RFA electrode can be visualized as it passes through the nodule, with the evolving ablation zone (arrow) encroaching on the pericardium (arrowheads). C, after re-inflation of the left lung, the ablation zone (arrow) clearly moves away from the pericardium (arrowheads).
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Case 2
A 79-yr-old female with chronic obstructive pulmonary disease and a history of left lower lobectomy for grade 4 non-small cell carcinoma 2 yr before admission presented for RFA of a nodule in the right middle lobe adjacent to an emphysematous bulla. She was not considered to be a surgical candidate because of her previous pulmonary resection and limited pulmonary reserve.
After induction of general anesthesia, a 37F left-sided double-lumen endotracheal tube was placed. After lung isolation, the solitary left lobe was ventilated with 100% O2 and the operative right lung was insufflated with air and CPAP (7.5 cm H2O) was applied. The patient maintained adequate oxygenation (Spo2 >95%) throughout the RFA, the operative lung field remained quiet, and no significant volume loss was observed during the procedure.
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Discussion
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Commonly used for treatment of solid organ tumors, RFA is a relatively new procedure for the treatment of pulmonary tumors. The first use of RFA for lung tumors in humans was reported in 2000 (6). There is a growing body of literature on the subject in general but limited information regarding the anesthetic management of patients during these procedures, despite the unique challenges these patients and procedures present.
Not surprisingly, injury to adjacent structures has been reported during RFA of intraabdominal tumors with serious consequences. It is logical to assume that thermal injury to critical organs and major vascular structures near the hilum of the lung may occur during RFA of pulmonary lesions. In fact, there are reports of fatal hemorrhage after RFA of lung tumors during and several days after the procedure (7,8). As a result, it has been recommended that only noncentral lesions be considered for RFA (9). Even with this precaution, lung isolation may still be prudent to protect the nonoperative lung in the event of severe bleeding. Reduction of tidal volumes delivered to the nonoperative lung (<7 mL/kg) can also facilitate placement of the RF probe by minimizing movement during respiration. Lung volumes can be more reliably maintained with administration of CPAP to the operative lung, thereby maximizing the distance of the RFA probe from the hilum and other structures. Finally, airway fires have been reported in a number of different circumstances, including thoracic surgery with use of CPAP and 100% oxygen (10–13). Although such fires have not been reported during RFA, there is a risk, particularly with administration of 100% O2 to the operative lung. CPAP to the nonventilated lung using air instead of oxygen minimizes the risk of combustion. By isolating the lungs, it is still possible to deliver 100% oxygen to the ventilated lung, which may be of particular importance in patients with marginal pulmonary function.
In summary, we describe the anesthetic management of two patients undergoing RFA of lung lesions. The evolving practice of image-guided interventional techniques presents an opportunity for anesthesiologists to use their expertise to increase the success and safety of these procedures.
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Footnotes
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Accepted for publication April 4, 2006.
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References
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Abstract
Introduction
