Anesth Anall: Vol. 57, July-Aug. 1978
Clinical Reports
ment exceed the improvement in myocardial perfusion and oxygenation.11 By increasing 0, consumption in the presence of a limited supply, it may be that the infusion of isoproterenol was the final precipitating factor in producing cardiac arrest. Cardiac standstill rather than ventricular fibrillation suggest myocardial hypoxia rather than hyperirritability. In summary, it appears that the mechanism of arrest was not so much through the wrong choice of agents or technics of anesthesia, but failure to appreciate the degree of cardiac decompensation and fluid overload. In retrospect, it Seems that the operation should have been delayed to give time for peritoneal dialysis, meanwhile relying on pericardial drainage to prevent tamponade.1, Unexplained bradycardia should alert the anesthesiologist to the possibility of hypoxia, and this should be excluded before resorting to drugs for its symptomatic treatment. Electrocardiographic monitoring is clearly inadequate for the detection of changes in cardiac performance; in our case ECG complexes were normal in the presence of cardiac standstill observed a t thoracotomy. Intra-arterial pressure monitoring, blood gas analyses, and a CVP line are strongly recommended in handling such poor-risk patients.
REFERENCES 1. Konchigeri HN, Levitsky S: Anesthetic considerations for pericardectomy in uremic pericardial effusion. Anesth Analg 55:378-382, 1976
2. Wylie WD, Churchill-Davidson HC: Anaes-
501
thesia and cardiac disease, in A Practice of Anaesthesia. Edited by W D Wylie and HC ChurchillDavidson. Chicago, Year Book Medical I'ublishers, 1972, pp 651-690 3. Kadis T,R, Gianelly R E : Heart and cardiovascular systems, in Anesthesia and Uncommon Diseases: Pathophysiological and Clinical Correlations. Edited by J Katz and LR Kadis. Philadelphia, W. B. Saunders, 1973, pp 203-216 4. Stanley TH, Weidauer HE: Anesthesia for the patient with cardiac tamponade. Anesth Anal5 52:llO-114, 1973
5. Weintraub HI>, Heistercamp DV, Coopeiman LH: Changes in plasma potassium concentration after depolarizing blockers in anaesthetized man. Rr d Anaesth 41;1048-1052, 1969 6. Roth F, Wuthrich H : The clinical importance of hyperkalaemia following suxamethonium administration. Br J Anaesth 41:311-316, 1969
7. Powell J N : Suxamethonium induced hyperkalaemia in a uremic patient. Br J Anaesth 42:80ti807, 1970 8. Koide M, Waud BE: Serum potassium concentrations after succinylcholine in patients with renal failure. Anesthesiology 36: 142.145, 1972 9. Wade OL, Bishop J M : Cardiac Output and Regional Blood How. Oxford, Blackwell Scientific Publications, 1962, p 91 10. Holloway EL, Stinson EB, Derby GC, ct al: Actions of drugs in patients early after cardiac surgery. Comparison of isoprotetenol and dopamine. Am J Cardiol 35:656-659, 1975
11. Mueller H, Ayres SM, Gianelli S, et al: Effect of isoproterenol, 1-norepinephrine and intraaortic counterpulsation on hemodynamics and myocardial metabolism in shock following acute myocardial infarction. Circulation 45: 335-351, 1972 12. Uraemic pericarditis. Editorial. Lancet 11941, 1977
Cardiac Arrest Following Pneumonectomy and Pericardiotomy JOSEPH L. SELTZER, M D *
H
of the heart through a pericardial defect is a recognized complication of pneumonectomy requiring pericardiotomy.lI' Since this can occur in the immediate postoperative period,l-3 the anesthesiologist must be aware of the possibility ERNIATION
and be able to make the diagnosis. The following case illustrates this point.
CASE REPORT A 33-year-old female with a bronchoscopic diagnosis of squamous-cell carcinoma of the
*Assistant Professor, Department of Anesthesiology, State University of New York, Upstate Medical Center, Syracuse, New York 13210 Accepted for publication: May 10, 1978
502
Clinical Reports
Anesth Analg Vol. 57,July-Aug. 1978
lung and a negative mediastinoscopy was scheduled for a right pneumonectomy. Preoperative evaluation, including pulmonary function studies, was within normal limits. Chest x-ray revealed a right hilar mass and a right upper lobe lesion. In the operating room the left radial artery was cannulated to monitor arterial blood gases. A central venous pressure line was not judged to be necessary and was not inserted. Anesthesia was induced with thiopental 300 mg and maintained with 0.5 to 1% haloIhane, pancuronium 4 mg, and 50:50 N,O: 0,. With the right lung retracted, Pao, ranged from 170 to 140 torr. Occasional transient ventricular extrasystoles were associated with retraction of the hilum. On one occasion, when these extrasystoles became multifocal, lidocaine 50 mg was given IV. With the exception of these episodes of dysrhythmia, the anesthetic was uneventful. It was necessary for the surgeon to open the right pericardium to complete the pneumonectomy. A 4-cm defect was made, and several sutures were placed to close it to less than 3 cm. At the conclusion of the procedure, spontaneous respiration resumed, and neostigmine 1.25 mg and atropine 0.5 mg were given to antagonize the residual neuromuscular block. The patient's vital capacity was judged to be satisfactory since she generated an adequate cough. She w a s extubated after receiving 100% 0, for about 5 minutes. She was then taken to the recovery room. The transit time was about 90 to 120 seconds. On arrival, she appeared cyanotic and palpable pulses had disappeared. She was ventilated by bag and mask and then reintubated. Simultaneously, external cardiac massage was begun. Almost immediately a palpable pulse returned, and blood pressure was recorded in the range of 80-100/40-60 mm Hg with a sinus rhythm of 90 to 100 beats/min. The patient was reactive but still had cyanosis of the head, neck, upper extremities, and upper thorax. A portable chest x-ray was immediately obtained and showed the heart to be occupying the right pleural cavity (fig 1). The patient was immediately returned to the operating room. Ketamine 100 mg, pancuronium 2 mg, and 50:50 N,O:O, were given and the right chest was reopened. The heart was found to have herniated through the pericardiotomy omnina and to have rotat& 180" posteriorly to anteriorly so that the left ventricle was presenting anteriorly
FIG 1. Portable chest x-ray taken in recovery rooni shows heait filling the right pleural space.
in the right pleural space. The heart was reduced to its appropriate position. T h e blood pressure increased to 120/80 mm Hg, the heart rate slowed to 80 beatstmin, and the cyanosis rapidly cleared. The pericardial defect was closed with a Dacron patch. T h e patient was extubated the next morning and made a n uneventful recovery. Figure 2 shows the patient's chest x-ray after extubation.
FIG2. Chest x-ray taken after extubation shows the normal appearance of the heart after a right .. pneumonectomy.
Aneath Analg Vol. 57, July-Aug. 1978
503
Clinical Reports
DISCUSSION The dramatic change in this patient's condition from reactive with spontaneous respirations to a cardiac and respiratory arrest indicated a catastrophic event occurred. With the resumption of circulation in the presence of artificial ventilation, the eyanosis of the upper body suggested superior vena cava obstruction. This was confirmed at reoperation. Previous reports indicate that if the heart herniates through an unclosed pericardiotomy, it usually does so in the immediate postoperative period1-3 although it may occur many hours postoperatively.1 The outcome has often been fatal due to damage occurring to the heart, which can become strangulated in the pericardial defect.'.' On occasion the diagnosis has been made only at autopsy.' The favorable outcome in this case as in others3 is the result of prompt diagnosis and surgical reduction.
rolling the patient to the operative side; ( 3) violent bouts of coughing; and ( 4 ) hyperinflation of the remaining lung. Our patient did cough several times prior to extubation and this possibly could have caused the herniation. In summary, a case of cardiac arrest following pneumonectomy requiring pericardiotomy is reported. The anesthesiologist is likely to see this complication since most previously reported cases have occurred in the immediate recovery period. In the event of inability to resuscitate a patient whose pericardium has been opened, a chest x-ray is indicated, and it would be wise to reopen the chest to rule out herniation of the heart before ceasing resuscitation efforts.
Yacoubl states that the precipitating factors in addition to the size and site of the defect in the pericardium include (1) suction applied to pleural drainage tubes; ( 2 )
2. Sharman VN, Bates M, Hunt RL: Herniation of the heart after intrapericardial pneumonectomy for bronchial carcinoma. Thorax 14:36-38, 1959 3. Kirchhof AC: Herniation of the heart: report of case. Anesthesiology 12:774, 1951
REFERENCES 1. Yacoub MH, Williams WG, Ahmad A: Strangulation of the heart following intrapericardial pneumonectomy. Thorax 23:261-265, 1968
Anesthetic Management of a Patient with Hereditary Fructose-1, 6-Diphosphatase Deficiency YASUHIKO HASHIMQTQ, M D * HIROMI WATANABE, M D t MITSUQ SATOU, M D + Senda i, Japans
H
fructose-l,6-diphospha~~tose; and ( 2 ) severe metabolic acidosis evi(FDPase) deficiency is a rare and denced by hyperventilation. Hepatomegaly little understood genetic disorder first de- and muscular hypotonia are frequent, and scribed by Baker and Winegrad in 1970.l fatty changes of the liver have been seen The clinical course of this disorder is char- without exception.I- 0 Mental development acterized by (1) recurrent episodes of hypo- and growth remain normal despite fructose glycemia precipitated by stress, such as intake.11 Up to 1977, 11 patients with acute infections, and by ingestion of fruc- FDPase deficiency from 3 European counEREDITARY
*Assistant Professor, Department of Anesthesiology ?Resident in Anesthesiology $Professor and Chairman, Department of Anesthesiology $Department of Anesthesiology, Tohoku University School of Medicine, Seiryo-machi 1-1, Sendai 980, Japan Address reprint requests to Dr. Hashimoto. Accepted for publication. April 18, 1978
Clinical Reports
ment exceed the improvement in myocardial perfusion and oxygenation.11 By increasing 0, consumption in the presence of a limited supply, it may be that the infusion of isoproterenol was the final precipitating factor in producing cardiac arrest. Cardiac standstill rather than ventricular fibrillation suggest myocardial hypoxia rather than hyperirritability. In summary, it appears that the mechanism of arrest was not so much through the wrong choice of agents or technics of anesthesia, but failure to appreciate the degree of cardiac decompensation and fluid overload. In retrospect, it Seems that the operation should have been delayed to give time for peritoneal dialysis, meanwhile relying on pericardial drainage to prevent tamponade.1, Unexplained bradycardia should alert the anesthesiologist to the possibility of hypoxia, and this should be excluded before resorting to drugs for its symptomatic treatment. Electrocardiographic monitoring is clearly inadequate for the detection of changes in cardiac performance; in our case ECG complexes were normal in the presence of cardiac standstill observed a t thoracotomy. Intra-arterial pressure monitoring, blood gas analyses, and a CVP line are strongly recommended in handling such poor-risk patients.
REFERENCES 1. Konchigeri HN, Levitsky S: Anesthetic considerations for pericardectomy in uremic pericardial effusion. Anesth Analg 55:378-382, 1976
2. Wylie WD, Churchill-Davidson HC: Anaes-
501
thesia and cardiac disease, in A Practice of Anaesthesia. Edited by W D Wylie and HC ChurchillDavidson. Chicago, Year Book Medical I'ublishers, 1972, pp 651-690 3. Kadis T,R, Gianelly R E : Heart and cardiovascular systems, in Anesthesia and Uncommon Diseases: Pathophysiological and Clinical Correlations. Edited by J Katz and LR Kadis. Philadelphia, W. B. Saunders, 1973, pp 203-216 4. Stanley TH, Weidauer HE: Anesthesia for the patient with cardiac tamponade. Anesth Anal5 52:llO-114, 1973
5. Weintraub HI>, Heistercamp DV, Coopeiman LH: Changes in plasma potassium concentration after depolarizing blockers in anaesthetized man. Rr d Anaesth 41;1048-1052, 1969 6. Roth F, Wuthrich H : The clinical importance of hyperkalaemia following suxamethonium administration. Br J Anaesth 41:311-316, 1969
7. Powell J N : Suxamethonium induced hyperkalaemia in a uremic patient. Br J Anaesth 42:80ti807, 1970 8. Koide M, Waud BE: Serum potassium concentrations after succinylcholine in patients with renal failure. Anesthesiology 36: 142.145, 1972 9. Wade OL, Bishop J M : Cardiac Output and Regional Blood How. Oxford, Blackwell Scientific Publications, 1962, p 91 10. Holloway EL, Stinson EB, Derby GC, ct al: Actions of drugs in patients early after cardiac surgery. Comparison of isoprotetenol and dopamine. Am J Cardiol 35:656-659, 1975
11. Mueller H, Ayres SM, Gianelli S, et al: Effect of isoproterenol, 1-norepinephrine and intraaortic counterpulsation on hemodynamics and myocardial metabolism in shock following acute myocardial infarction. Circulation 45: 335-351, 1972 12. Uraemic pericarditis. Editorial. Lancet 11941, 1977
Cardiac Arrest Following Pneumonectomy and Pericardiotomy JOSEPH L. SELTZER, M D *
H
of the heart through a pericardial defect is a recognized complication of pneumonectomy requiring pericardiotomy.lI' Since this can occur in the immediate postoperative period,l-3 the anesthesiologist must be aware of the possibility ERNIATION
and be able to make the diagnosis. The following case illustrates this point.
CASE REPORT A 33-year-old female with a bronchoscopic diagnosis of squamous-cell carcinoma of the
*Assistant Professor, Department of Anesthesiology, State University of New York, Upstate Medical Center, Syracuse, New York 13210 Accepted for publication: May 10, 1978
502
Clinical Reports
Anesth Analg Vol. 57,July-Aug. 1978
lung and a negative mediastinoscopy was scheduled for a right pneumonectomy. Preoperative evaluation, including pulmonary function studies, was within normal limits. Chest x-ray revealed a right hilar mass and a right upper lobe lesion. In the operating room the left radial artery was cannulated to monitor arterial blood gases. A central venous pressure line was not judged to be necessary and was not inserted. Anesthesia was induced with thiopental 300 mg and maintained with 0.5 to 1% haloIhane, pancuronium 4 mg, and 50:50 N,O: 0,. With the right lung retracted, Pao, ranged from 170 to 140 torr. Occasional transient ventricular extrasystoles were associated with retraction of the hilum. On one occasion, when these extrasystoles became multifocal, lidocaine 50 mg was given IV. With the exception of these episodes of dysrhythmia, the anesthetic was uneventful. It was necessary for the surgeon to open the right pericardium to complete the pneumonectomy. A 4-cm defect was made, and several sutures were placed to close it to less than 3 cm. At the conclusion of the procedure, spontaneous respiration resumed, and neostigmine 1.25 mg and atropine 0.5 mg were given to antagonize the residual neuromuscular block. The patient's vital capacity was judged to be satisfactory since she generated an adequate cough. She w a s extubated after receiving 100% 0, for about 5 minutes. She was then taken to the recovery room. The transit time was about 90 to 120 seconds. On arrival, she appeared cyanotic and palpable pulses had disappeared. She was ventilated by bag and mask and then reintubated. Simultaneously, external cardiac massage was begun. Almost immediately a palpable pulse returned, and blood pressure was recorded in the range of 80-100/40-60 mm Hg with a sinus rhythm of 90 to 100 beats/min. The patient was reactive but still had cyanosis of the head, neck, upper extremities, and upper thorax. A portable chest x-ray was immediately obtained and showed the heart to be occupying the right pleural cavity (fig 1). The patient was immediately returned to the operating room. Ketamine 100 mg, pancuronium 2 mg, and 50:50 N,O:O, were given and the right chest was reopened. The heart was found to have herniated through the pericardiotomy omnina and to have rotat& 180" posteriorly to anteriorly so that the left ventricle was presenting anteriorly
FIG 1. Portable chest x-ray taken in recovery rooni shows heait filling the right pleural space.
in the right pleural space. The heart was reduced to its appropriate position. T h e blood pressure increased to 120/80 mm Hg, the heart rate slowed to 80 beatstmin, and the cyanosis rapidly cleared. The pericardial defect was closed with a Dacron patch. T h e patient was extubated the next morning and made a n uneventful recovery. Figure 2 shows the patient's chest x-ray after extubation.
FIG2. Chest x-ray taken after extubation shows the normal appearance of the heart after a right .. pneumonectomy.
Aneath Analg Vol. 57, July-Aug. 1978
503
Clinical Reports
DISCUSSION The dramatic change in this patient's condition from reactive with spontaneous respirations to a cardiac and respiratory arrest indicated a catastrophic event occurred. With the resumption of circulation in the presence of artificial ventilation, the eyanosis of the upper body suggested superior vena cava obstruction. This was confirmed at reoperation. Previous reports indicate that if the heart herniates through an unclosed pericardiotomy, it usually does so in the immediate postoperative period1-3 although it may occur many hours postoperatively.1 The outcome has often been fatal due to damage occurring to the heart, which can become strangulated in the pericardial defect.'.' On occasion the diagnosis has been made only at autopsy.' The favorable outcome in this case as in others3 is the result of prompt diagnosis and surgical reduction.
rolling the patient to the operative side; ( 3) violent bouts of coughing; and ( 4 ) hyperinflation of the remaining lung. Our patient did cough several times prior to extubation and this possibly could have caused the herniation. In summary, a case of cardiac arrest following pneumonectomy requiring pericardiotomy is reported. The anesthesiologist is likely to see this complication since most previously reported cases have occurred in the immediate recovery period. In the event of inability to resuscitate a patient whose pericardium has been opened, a chest x-ray is indicated, and it would be wise to reopen the chest to rule out herniation of the heart before ceasing resuscitation efforts.
Yacoubl states that the precipitating factors in addition to the size and site of the defect in the pericardium include (1) suction applied to pleural drainage tubes; ( 2 )
2. Sharman VN, Bates M, Hunt RL: Herniation of the heart after intrapericardial pneumonectomy for bronchial carcinoma. Thorax 14:36-38, 1959 3. Kirchhof AC: Herniation of the heart: report of case. Anesthesiology 12:774, 1951
REFERENCES 1. Yacoub MH, Williams WG, Ahmad A: Strangulation of the heart following intrapericardial pneumonectomy. Thorax 23:261-265, 1968
Anesthetic Management of a Patient with Hereditary Fructose-1, 6-Diphosphatase Deficiency YASUHIKO HASHIMQTQ, M D * HIROMI WATANABE, M D t MITSUQ SATOU, M D + Senda i, Japans
H
fructose-l,6-diphospha~~tose; and ( 2 ) severe metabolic acidosis evi(FDPase) deficiency is a rare and denced by hyperventilation. Hepatomegaly little understood genetic disorder first de- and muscular hypotonia are frequent, and scribed by Baker and Winegrad in 1970.l fatty changes of the liver have been seen The clinical course of this disorder is char- without exception.I- 0 Mental development acterized by (1) recurrent episodes of hypo- and growth remain normal despite fructose glycemia precipitated by stress, such as intake.11 Up to 1977, 11 patients with acute infections, and by ingestion of fruc- FDPase deficiency from 3 European counEREDITARY
*Assistant Professor, Department of Anesthesiology ?Resident in Anesthesiology $Professor and Chairman, Department of Anesthesiology $Department of Anesthesiology, Tohoku University School of Medicine, Seiryo-machi 1-1, Sendai 980, Japan Address reprint requests to Dr. Hashimoto. Accepted for publication. April 18, 1978
