Airway Obstruction Mimicking Superior Vena Cava Syndrome in a Patient Undergoing Dialysis Graft Revision after Ultrasound-Guided Supraclavicular Nerve Block Veneet Jassal, MD, and Paul E. Bigeleisen, MD A 25-year-old man presented for revision of a dialysis fistula in his left upper arm. An ultrasoundguided left supraclavicular block was performed, and 4 hours later during wound closure, the patient developed intermittent airway obstruction accompanied by edema of the face and upper airway. Superior vena cava syndrome was suspected, and awake fiberoptic tracheal intubation was performed. Partial obstruction of the left brachiocephalic vein and right internal jugular vein were identified while the patient was in the radiology suite. Sympathetic block and increased venous return from the left arm likely contributed to his airway obstruction that mimicked superior vena cava syndrome. (A&A Case Reports. 2014;2:96–8.)
A
irway obstruction after supraclavicular nerve block has been reported as a consequence of inadvertent recurrent laryngeal nerve block and pneumothorax.1 Delayed superior vena cava syndrome has also been reported after the completion of a dialysis fistula.2,3 We report the case of a patient developing airway obstruction and facial edema after a supraclavicular block and the revision of a dialysis fistula. These symptoms, which mimicked those of superior vena cava syndrome, were caused by stenosis of the patient’s left brachiocephalic vein, thrombus of the right internal jugular vein, and increased venous return secondary to sympathectomy of the left upper extremity after nerve block. The patient agreed to publication of this case report.
CASE DESCRIPTION
A 25-year-old, 63 kg man, who was anephric secondary to focal glomerulo sclerosis, presented for the revision of a dialysis fistula in his left upper arm. His medical history included hypertension treated with labetalol, lisinopril, nifedipine, hydralazine, minoxidil, and cinacalcet. He also took oral warfarin 7.5 mg every other day for a history of thrombosis of his left subclavian vein and right and left internal jugular veins. Thrombosis of these vessels had resolved on angiograms 3 months before his current surgery, and his warfarin had been stopped 7 days before the surgery at which his international normalized ratio had been 2.1. He denied any other history or symptoms of vascular disease. Because the patient had discontinued his warfarin 7 days before surgery, the anesthesia care team elected not From the Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, Maryland. Accepted for publication October 4, 2013. Funding: Departmental. The authors declare no conflicts of interest. Address correspondence to Paul E. Bigeleisen, MD, Department of Anesthesiology, University of Maryland School of Medicine, 22 South Greene St., Baltimore MD 21201. Address e-mail to [email protected]. Copyright © 2014 International Anesthesia Research Society DOI: 10.1213/XAA.0000000000000008
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to measure his international normalized ratio on the day of surgery and no additional anticoagulation was used before surgery. Physical examination showed a patient with normal heart and lung sounds, normal neck extension, and a Mallampati class II airway. On the day of his surgery, his arterial blood pressure was 140/78 mm Hg, with a heart rate of 86 bpm. Pertinent laboratory values included hemoglobin 9.8 gm/ dL, platelet count 181,000/mL, potassium 4.5 meq/L, and creatinine 2.6 mg/dL. The patient agreed to a supraclavicular nerve block and sedation for the procedure. Standard monitors were applied, and a left-sided ultrasound-guided supraclavicular block was performed by injecting 5 mL bupivacaine (5 mg/mL) into the superior, middle, and inferior trunks of the plexus (total injection volume = 15 mL). Fifteen milliliter of the same solution was also injected into the distribution of the intercostal brachial nerve in the patient’s upper arm. There was no evidence of vascular puncture of the vessels in the patient’s neck or arm during the nerve block procedure. The surgeon declined to administer heparin before or during the surgery. The patient was sedated with propofol (50–100 mcg/kg/ min), and surgery proceeded uneventfully for 2 hours when anastomosis of his artery to the cephalic vein was completed. During completion of the anastomosis, the surgeon noted venous distension that he suggested may have been caused by thrombosis proximal to the subclavian dialysis catheter. Thirty minutes later, the patient developed intermittent respiratory obstruction relieved by insertion of an oral airway. Ninety minutes later, while the surgeon was closing the incision, the patient developed significantly more airway obstruction. The propofol infusion was discontinued, and the patient’s ventilation was assisted using a mask and positive pressure ventilation. At this time, the patient’s sclerae were noted to be markedly edematous, and the anterior area of the patient’s neck and tongue were tense and swollen. A diagnosis of superior vena cava syndrome was made. By this time, the patient was awake and responsive but markedly dyspneic and unable to speak. The head of the patient’s bed was elevated, and the trachea was intubated awake using fiberoptic guidance and a 7.0 endotracheal tube. Endoscopy April 15, 2014 • Volume 2 • Number 8
Figure 1. Angioplasty catheter in place with guidewire (GW) passed distal to the obstruction. Image shows decreased drainage from the left axillary vein (1) to the subclavian vein (2) and left brachiocephalic vein (3). There is increased blood flow through some collateral veins (4), and the “*” highlights the engorged paravertebral collateral veins.
showed a markedly edematous upper airway, larynx, and glottis. During this time, the patient’s vital signs were normal, and his oxyhemoglobin saturation was 92%. The patient remained in the operating room for an hour anesthetized with sevoflurane with his head elevated while the surgeon made arrangements to have the patient’s
Figure 3. Spot radiograph showing guidewire (GW) from inferior vena cava (1) to the left subclavian vein (2). There were multiple attempts to relieve obstruction using a balloon visible in the subclavian vein.
superior vena cava syndrome evaluated in the radiology suite. During this time, the edema in the patient’s face and neck diminished. In the radiology suite, computed tomography and vascular studies showed a stenosis in the left brachiocephalic vein and thrombosis in the right internal jugular vein (Fig. 1). Since the patient’s condition was stable and he was appropriately responsive, the surgeon and radiologist elected to wait 48 hours to determine whether the airway edema would resolve with the patient in the headup position and with the aid of dialysis. During this time, the patient’s trachea remained intubated. The edema in the patient’s face, neck, and airway remained; he was returned to the radiology suite, and the stricture in his left brachiocephalic vein was dilated (Figs. 2, 3 and 4). Over the next 24 hours, the edema resolved, and his trachea was extubated uneventfully 48 hours later. Vascular studies after his brachiocephalic vein dilation showed his central venous pressure to be normal.
DISCUSSION
Figure 2. Fluoroscopy of dye injection into the subclavian vein (1) distal to the obstruction, highlighting drainage to the paravertebral collateral veins (denoted by *) instead of draining into the left brachiocephalic vein (2) of partial flow restored after angioplasty. A guidewire (GW) has been passed through the obstruction.
April 15, 2014 • Volume 2 • Number 8
We postulate that the combination of completion of the fistula and sympathetic block increased venous flow into the left brachiocephalic vein. Since this vein was stenotic and the right internal jugular vein was thrombosed, venous outflow from the head through the left internal jugular vein was reduced. This likely resulted in edema of the face and airway mimicking superior vena cava syndrome. Supine posture for >4 hours may also have contributed to this problem. When questioned postoperatively, the patient stated he had developed problems sleeping supine in the 3 weeks before his surgery. To alleviate this problem, he had begun sleeping with his head elevated. His nephrologist had attributed this to fluid overload secondary to incomplete dialysis because his original fistula was functioning poorly. The patient had neglected to tell
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Airway Obstruction After Supraclavicular Nerve Block
Figure 4. Restoration of normal venous drainage from the subclavian vein (1) to the brachiocephalic vein (2). Collateral drainage is no longer present. Guidewire (GW).
us this when we examined him preoperatively, and we had failed to ask about his sleep habits because he was breathing comfortably in the upright position. In hindsight, his new difficulty while sleeping supine may have been due to intermittent decreased venous drainage from his head secondary to a stenosed left brachiocephalic
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vein and occluded right internal jugular vein as well as fluid overload. Venous thrombosis can be treated either surgically or pharmacologically. In the case of a surgical technique, the clot is removed after passing a Fogarty catheter into the vein or by opening the fistula directly and removing the clot with subsequent repair. In nonemergent cases, tissue plasminogen activator may be used to dissolve the clot. When stenosis is diagnosed, dilation under radiographic guidance is the preferred technique. Better preoperative anticoagulation may have prevented rethrombosis of the patient’s right internal jugular vein, but it would not have prevented stenosis in his subclavian artery that was likely due to inflammation and scarring after previous thrombosis. Delayed superior vena cava syndrome after arteriovenous fistula creation has been reported.2,3 In most cases, this is caused by an indwelling dialysis catheter in the jugular or subclavian vein and stenosis or thrombosis of the jugular or subclavian vein on the contralateral side. We report this case of decreased venous drainage from the head to remind readers that this syndrome may occur in the acute setting of vascular graft repair under regional anesthesia. E REFERENCES 1. Urmey W. Case studies of regional anesthesia. In: Finucane B, ed. Complications of Regional Anesthesia. 2nd ed. New York, NY: Springer, 2007:415–7 2. Madan AK, Allmon JC, Harding M, Cheng SS, Slakey DP. Dialysis access-induced superior vena cava syndrome. Am Surg 2002;68:904–6 3. Molhem A, Sabry A, Bawadekji H, Al Saran K. Superior vena cava syndrome in hemodialysis patient. Saudi J Kidney Dis Transpl 2011;22:381–6
A & A case reports
A
irway obstruction after supraclavicular nerve block has been reported as a consequence of inadvertent recurrent laryngeal nerve block and pneumothorax.1 Delayed superior vena cava syndrome has also been reported after the completion of a dialysis fistula.2,3 We report the case of a patient developing airway obstruction and facial edema after a supraclavicular block and the revision of a dialysis fistula. These symptoms, which mimicked those of superior vena cava syndrome, were caused by stenosis of the patient’s left brachiocephalic vein, thrombus of the right internal jugular vein, and increased venous return secondary to sympathectomy of the left upper extremity after nerve block. The patient agreed to publication of this case report.
CASE DESCRIPTION
A 25-year-old, 63 kg man, who was anephric secondary to focal glomerulo sclerosis, presented for the revision of a dialysis fistula in his left upper arm. His medical history included hypertension treated with labetalol, lisinopril, nifedipine, hydralazine, minoxidil, and cinacalcet. He also took oral warfarin 7.5 mg every other day for a history of thrombosis of his left subclavian vein and right and left internal jugular veins. Thrombosis of these vessels had resolved on angiograms 3 months before his current surgery, and his warfarin had been stopped 7 days before the surgery at which his international normalized ratio had been 2.1. He denied any other history or symptoms of vascular disease. Because the patient had discontinued his warfarin 7 days before surgery, the anesthesia care team elected not From the Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, Maryland. Accepted for publication October 4, 2013. Funding: Departmental. The authors declare no conflicts of interest. Address correspondence to Paul E. Bigeleisen, MD, Department of Anesthesiology, University of Maryland School of Medicine, 22 South Greene St., Baltimore MD 21201. Address e-mail to [email protected]. Copyright © 2014 International Anesthesia Research Society DOI: 10.1213/XAA.0000000000000008
96 cases-anesthesia-analgesia.org
to measure his international normalized ratio on the day of surgery and no additional anticoagulation was used before surgery. Physical examination showed a patient with normal heart and lung sounds, normal neck extension, and a Mallampati class II airway. On the day of his surgery, his arterial blood pressure was 140/78 mm Hg, with a heart rate of 86 bpm. Pertinent laboratory values included hemoglobin 9.8 gm/ dL, platelet count 181,000/mL, potassium 4.5 meq/L, and creatinine 2.6 mg/dL. The patient agreed to a supraclavicular nerve block and sedation for the procedure. Standard monitors were applied, and a left-sided ultrasound-guided supraclavicular block was performed by injecting 5 mL bupivacaine (5 mg/mL) into the superior, middle, and inferior trunks of the plexus (total injection volume = 15 mL). Fifteen milliliter of the same solution was also injected into the distribution of the intercostal brachial nerve in the patient’s upper arm. There was no evidence of vascular puncture of the vessels in the patient’s neck or arm during the nerve block procedure. The surgeon declined to administer heparin before or during the surgery. The patient was sedated with propofol (50–100 mcg/kg/ min), and surgery proceeded uneventfully for 2 hours when anastomosis of his artery to the cephalic vein was completed. During completion of the anastomosis, the surgeon noted venous distension that he suggested may have been caused by thrombosis proximal to the subclavian dialysis catheter. Thirty minutes later, the patient developed intermittent respiratory obstruction relieved by insertion of an oral airway. Ninety minutes later, while the surgeon was closing the incision, the patient developed significantly more airway obstruction. The propofol infusion was discontinued, and the patient’s ventilation was assisted using a mask and positive pressure ventilation. At this time, the patient’s sclerae were noted to be markedly edematous, and the anterior area of the patient’s neck and tongue were tense and swollen. A diagnosis of superior vena cava syndrome was made. By this time, the patient was awake and responsive but markedly dyspneic and unable to speak. The head of the patient’s bed was elevated, and the trachea was intubated awake using fiberoptic guidance and a 7.0 endotracheal tube. Endoscopy April 15, 2014 • Volume 2 • Number 8
Figure 1. Angioplasty catheter in place with guidewire (GW) passed distal to the obstruction. Image shows decreased drainage from the left axillary vein (1) to the subclavian vein (2) and left brachiocephalic vein (3). There is increased blood flow through some collateral veins (4), and the “*” highlights the engorged paravertebral collateral veins.
showed a markedly edematous upper airway, larynx, and glottis. During this time, the patient’s vital signs were normal, and his oxyhemoglobin saturation was 92%. The patient remained in the operating room for an hour anesthetized with sevoflurane with his head elevated while the surgeon made arrangements to have the patient’s
Figure 3. Spot radiograph showing guidewire (GW) from inferior vena cava (1) to the left subclavian vein (2). There were multiple attempts to relieve obstruction using a balloon visible in the subclavian vein.
superior vena cava syndrome evaluated in the radiology suite. During this time, the edema in the patient’s face and neck diminished. In the radiology suite, computed tomography and vascular studies showed a stenosis in the left brachiocephalic vein and thrombosis in the right internal jugular vein (Fig. 1). Since the patient’s condition was stable and he was appropriately responsive, the surgeon and radiologist elected to wait 48 hours to determine whether the airway edema would resolve with the patient in the headup position and with the aid of dialysis. During this time, the patient’s trachea remained intubated. The edema in the patient’s face, neck, and airway remained; he was returned to the radiology suite, and the stricture in his left brachiocephalic vein was dilated (Figs. 2, 3 and 4). Over the next 24 hours, the edema resolved, and his trachea was extubated uneventfully 48 hours later. Vascular studies after his brachiocephalic vein dilation showed his central venous pressure to be normal.
DISCUSSION
Figure 2. Fluoroscopy of dye injection into the subclavian vein (1) distal to the obstruction, highlighting drainage to the paravertebral collateral veins (denoted by *) instead of draining into the left brachiocephalic vein (2) of partial flow restored after angioplasty. A guidewire (GW) has been passed through the obstruction.
April 15, 2014 • Volume 2 • Number 8
We postulate that the combination of completion of the fistula and sympathetic block increased venous flow into the left brachiocephalic vein. Since this vein was stenotic and the right internal jugular vein was thrombosed, venous outflow from the head through the left internal jugular vein was reduced. This likely resulted in edema of the face and airway mimicking superior vena cava syndrome. Supine posture for >4 hours may also have contributed to this problem. When questioned postoperatively, the patient stated he had developed problems sleeping supine in the 3 weeks before his surgery. To alleviate this problem, he had begun sleeping with his head elevated. His nephrologist had attributed this to fluid overload secondary to incomplete dialysis because his original fistula was functioning poorly. The patient had neglected to tell
cases-anesthesia-analgesia.org
97
Airway Obstruction After Supraclavicular Nerve Block
Figure 4. Restoration of normal venous drainage from the subclavian vein (1) to the brachiocephalic vein (2). Collateral drainage is no longer present. Guidewire (GW).
us this when we examined him preoperatively, and we had failed to ask about his sleep habits because he was breathing comfortably in the upright position. In hindsight, his new difficulty while sleeping supine may have been due to intermittent decreased venous drainage from his head secondary to a stenosed left brachiocephalic
98 cases-anesthesia-analgesia.org
vein and occluded right internal jugular vein as well as fluid overload. Venous thrombosis can be treated either surgically or pharmacologically. In the case of a surgical technique, the clot is removed after passing a Fogarty catheter into the vein or by opening the fistula directly and removing the clot with subsequent repair. In nonemergent cases, tissue plasminogen activator may be used to dissolve the clot. When stenosis is diagnosed, dilation under radiographic guidance is the preferred technique. Better preoperative anticoagulation may have prevented rethrombosis of the patient’s right internal jugular vein, but it would not have prevented stenosis in his subclavian artery that was likely due to inflammation and scarring after previous thrombosis. Delayed superior vena cava syndrome after arteriovenous fistula creation has been reported.2,3 In most cases, this is caused by an indwelling dialysis catheter in the jugular or subclavian vein and stenosis or thrombosis of the jugular or subclavian vein on the contralateral side. We report this case of decreased venous drainage from the head to remind readers that this syndrome may occur in the acute setting of vascular graft repair under regional anesthesia. E REFERENCES 1. Urmey W. Case studies of regional anesthesia. In: Finucane B, ed. Complications of Regional Anesthesia. 2nd ed. New York, NY: Springer, 2007:415–7 2. Madan AK, Allmon JC, Harding M, Cheng SS, Slakey DP. Dialysis access-induced superior vena cava syndrome. Am Surg 2002;68:904–6 3. Molhem A, Sabry A, Bawadekji H, Al Saran K. Superior vena cava syndrome in hemodialysis patient. Saudi J Kidney Dis Transpl 2011;22:381–6
A & A case reports
