Anesth Analg 2004;98:1160-1163
© 2004 International Anesthesia Research Society
doi: 10.1213/01.ANE.0000101982.75084.F2
OBSTETRIC ANESTHESIA
Perioperative Management with Epidural Anesthesia for a Parturient with Superior Vena Caval Obstruction
Asokumar Buvanendran, MD*,
Pouya Mohajer, MD*,
Xavier Pombar, MD
, and
Kenneth J. Tuman, MD*
Departments of *Anesthesiology and
Obstetrics and Gynecology, Rush University Medical Center, Chicago, Illinois
Address correspondence and reprint requests to Asokumar Buvanendran, MD, Department of Anesthesiology, Rush Medical College, 1653 W. Congress Parkway, Chicago, IL 60612. Address e-mail to Asokumar{at}aol.com
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Abstract
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Perioperative management of patients with superior vena cava obstruction presents an anesthetic challenge because of severe cardiopulmonary compromise. This is particularly important in the parturient because of increased upper airway edema and inferior vena caval compression. We describe the management of a parturient who presented at 34 wk of gestation with signs and symptoms of superior vena cava obstruction from metastatic breast cancer. The patient was scheduled for a cesarean delivery followed by chemotherapy, as other therapies were deemed excessively risky because of the anatomic characteristics of the large mediastinal mass. This report describes the successful use of regional anesthesia in this setting and discusses the relevant anesthetic and perioperative management considerations for this complex scenario.
IMPLICATIONS: Perioperative management of patients with superior vena caval obstruction presents an anesthetic challenge because of the severe cardiopulmonary compromise. This case report describes a parturient who presented for cesarean delivery with superior vena caval obstruction resulting from metastasis from breast cancer.
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Introduction
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Superior vena cava obstruction (SVCO) may present as an acute or subacute process associated with a variety of clinical features. SVCO may present a challenge for anesthetic management because of potential airway and cardiovascular compromise. This is particularly important in the parturient because of increased upper airway edema and aorta-caval compression by the gravid uterus (1). The optimal anesthetic management of patients with SVCO has not been determined (2). Although spinal and epidural anesthesia cause a mild decrease in systemic vascular resistance (afterload), the effect on the capacitance vessels (pooling of blood) is much greater, resulting in decreased venous return (preload) (1) and leading to the notion that epidural anesthesia is relatively contraindicated in patients with conditions such as hypertrophic cardiomyopathy and SVCO. Nonetheless, carefully titrated and monitored epidural anesthesia has been successfully used for surgery in patients with hypertrophic cardiomyopathy (3). We describe the anesthetic management with an epidural technique for cesarean delivery in a parturient with a large anterior mediastinal mass that extended into and nearly occluded the superior vena cava (SVC).
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Case Report
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A 31-yr-old female (Gravida 2, Para 1) presented at 34 wk of gestation for repeat cesarean delivery. She had a history of hypothyroidism, asthma, gestational diabetes mellitus, and right breast lumpectomy with axillary node dissection status postchemotherapy (5-Fluorouracil and methotrexate) and radiation (for breast carcinoma 4 yr ago). The patient had a progressively worsening feeling of fullness in the head and neck, dyspnea and orthopnea (3–4 wk before presentation), dilation of chest wall veins, headaches, and occasional visual disturbances (blind spots lasting 40–60 min). On physical examination, the patient had a class I airway, distended neck veins with clear, equal breath sounds bilaterally, and no cardiac murmurs. A chest radiograph revealed a widened upper mediastinum. Fine needle aspiration of a right supraclavicular lymph node led to the diagnosis of recurrence of breast cancer. Computed tomography (CT) with radiocontrast showed a 6.4 x 5.1 cm lesion in the right retrosternal area at the level of the aortic arch, invading the SVC with almost complete obstruction (Figure 1). Adjacent to this lesion was another 1.6 x 1.7 cm soft tissue mass in the SVC allowing only a trickle of blood flow. Furthermore, there were multiple soft-tissue nodules throughout both lungs, although there was no compression of the trachea. In addition CT identified low-density lesions within the liver consistent with metastatic disease. The patient was scheduled for a cesarean delivery followed by chemotherapy because radiotherapy to reduce the tumor mass before surgery was considered to be excessively risky because of the location of the tumor. In addition to radiation, intravascular stenting is another palliative measure that could be undertaken for SVCO before surgery (2), although this patient was not deemed a candidate for that approach because of the anatomic location of the tumor relative to the surrounding structures. A transthoracic echocardiogram showed a normally functioning myocardium with no evidence for thrombus in the cardiac chambers or in the inferior vena cava (IVC).
Considering all aspects of the patient’s medical status, a regional anesthetic was planned. Appropriate personnel were consulted, including a cardiothoracic surgical team along with the perfusionist staff, which was immediately available during the operative procedure. On arrival in the operating room, the patient was placed in a semi-Fowler’s position secondary to severe orthopnea, and received oxygen via a nasal cannula. Left uterine displacement was maintained whenever the patient was supine. IV access was established via the left foot (16-gauge) and the left hand (18-gauge), and a left radial arterial catheter was inserted. Arterial blood gas values remained within normal ranges during the procedure. A 9F introducer sheath was placed in the right femoral vein and a venous pressure of 20 mm Hg was measured. An epidural catheter was placed in the sitting position (L3-4) and after a negative test dose (lidocaine 1.5% with epinephrine 1:200,000, 3 mL), incremental doses of lidocaine 2% with epinephrine 1:200,000 plus fentanyl 100 µg were administered until a T4-5 sensory blockade was achieved (15 mL total over 30 min). Fetal heart rate monitoring showed no abnormality during this time. The patient received 500 mL of colloid before administration of epidural anesthesia and received a total of 2300 mL of lactated Ringer’s solution for the entire duration of surgery. After an uneventful cesarean delivery, a 2.4 kg male infant was delivered (Apgar scores, 6/8 at 1 and 5 min). Immediately after delivery the venous pressure decreased to 7 mm Hg. Preservative-free morphine sulfate (2 mg) was administered epidurally, and the epidural catheter was subsequently removed because anticoagulation was to be used postoperatively. The next day the patient received chemotherapy; she was subsequently discharged home on postoperative day 4 and continued with chemotherapy as an outpatient.
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Discussion
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Increased numbers of young breast cancer patients will be seeking medical advice about pregnancy because oophorectomy is no longer performed adjuvantly and more women are bearing children in later years (4). Pregnancy-associated breast cancer has been defined as the diagnosis of breast cancer made during pregnancy or within 1 year afterwards. It is estimated to have an incidence of between 0.2% and 3.8%. Gestational hormones of pregnancy (4,5) may activate dormant micro-metastases of breast carcinoma. The recurrence of breast cancer is infrequent when the interval between treatment of breast carcinoma and pregnancy (3) is more than 2 years (the patient in discussion waited more than 4 years). A small group of patients with breast cancer and pregnancy have been compared to nonparturients with breast cancer and no effect of pregnancy on survival was demonstrated (6).
In malignancy-associated SVC syndrome, treatment is generally directed to the malignant disease process. Treatment modalities available for SVCO include local radiation (determined to be risky in this patient, given the extent of spread), chemotherapy, and steroids (only useful for patients with SVCO from lymphoma). Diuretic therapy is occasionally useful (7) but was not attempted because of concerns of further reducing preload. Because of the urgent need to initiate chemotherapy for this anterior mediastinal mass, delivery was planned at 34 weeks of gestation.
Anterior mediastinal mass combined with SVCO can present a challenge for general anesthesia because of severe hemodynamic compromise secondary to compression of the heart and great vessels. Positive pressure ventilation will exacerbate hemodynamic instability by increasing intrathoracic pressure, rapidly decreasing venous return, and potentially compromising an already narrowed parturient airway (8). Intraoperative mortality secondary to cardiac compression without evidence of tracheal obstruction has been reported from masses in the mediastinum, (9,10) although preoperative transthoracic echocardiographic findings indicated that the likelihood of direct cardiac compression was remote. IV induction and maintenance of general anesthesia for patients with SVCO has been associated with increased risks of difficult intubation, airway edema and obstruction as well as vocal cord paralysis (9).
There is no one single technique or algorithm that has been shown to be most effective for the anesthetic management of patients with SVCO syndrome (2). In the obstetric population, choice of regional anesthesia is a valuable alternative that avoids the exacerbating effects of positive pressure ventilation and a potentially more difficult tracheal intubation procedure. Although preoperative testing did not reveal evidence of airway compromise, the presence of an intrathoracic mass may have contributed to the signs of orthopnea at the time of cesarean delivery.
Epidural anesthesia was preferentially chosen over spinal anesthesia for this patient because of the ability to administer local anesthetic incrementally, thus potentially attenuating the speed of onset and extent of sympathectomy and producing minimal changes in the hemodynamics by facilitating compensatory interventions. We considered the risks of clinically significant hypotension in this patient to be potentially greater with institution of positive pressure ventilation during general anesthesia but acknowledge that a carefully titrated regional technique also carries a finite risk of hemodynamic instability.
In patients with SVCO, the vertebral venous plexus may be enlarged, making epidural catheterization more risky (11). The azygos venous system is the primary pathway for venous return when the SVCO occurs inferior to the entrance of the azygos vein. This system includes the azygos vein, the hemiazygos vein, and the connecting lumbar vein (7). In an analysis of collateral blood flow in SVCO by CT scan, the paravertebral veins were engorged in 66.6% of the scans studied (12). This compounds the engorgement of epidural veins resulting from uterine enlargement and IVC compression during pregnancy, leading to increased risk for intravascular penetration when placing a catheter in the epidural space. In the event of intravascular entry of the epidural needle and the possibility of cardiopulmonary bypass, we anticipated postponing the nonemergent surgery to be conservative, as done by other authors (13). Notably, a study by Pastor et al. (14) showed no adverse effects in 714 patients who had an epidural catheter placed 1 hour before heparinization for cardiopulmonary bypass, including 1.5% of the patients who had a bloody tap from an 18-gauge epidural needle. SVCO has also been shown to increase the epidural pressure and increase the extent of epidural analgesia; this is probably attributable to the decreased volume of the epidural space by venous enlargement (15). Although the combined spinal-epidural (CSE) anesthetic technique has been associated with greater patient satisfaction (16) and less failure than an epidural technique, the potential for severe hypotension was considered to be of unwarranted risk in this patient with SVCO. Notably however, there is a report of using CSE for a parturient with peripartum dilated cardiomyopathy for cesarean delivery (17) with no postoperative complications. More rapid afterload reduction induced by spinal anesthesia may be better tolerated in patients with cardiomyopathy than those with the pathophysiology of our patient.
Preinduction intravascular fluid administration (2) with colloid (18,19) and using lower extremity venous return with avoidance of aortocaval compression were essential to avoid hypotension during progressive sympathectomy in our patient with SVCO. Although not required in this case, plans were made to turn the patient to the full lateral or even the prone position (20) if the combined effects of SVC and IVC compression resulted in hypotension or signs of fetal distress before surgery. Pharmacological methods of hemodynamic support were immediately available for this patient, and as in this case, cardiopulmonary bypass capability should be available regardless of the anesthetic technique chosen. In the event that regional anesthesia failed or cardiopulmonary instability required tracheal intubation, we were prepared to perform fiberoptic intubation, assessing for dynamic airway collapse and the need for more aggressive cardiorespiratory management, including the use of a rigid ventilating bronchoscope and cardiopulmonary bypass.
In summary, we describe the successful management of regional anesthesia for cesarean delivery in a parturient with SVCO syndrome and reviewed the relevant management considerations for this complex scenario.
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References
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Accepted for publication October 3, 2003.
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Abstract
Introduction
