Letters to Editor 4.
Zhang X, Chen M, Li Q. The ProSeal Laryngeal Mask Airway is more effective than the LMA-Classic in pediatric anesthesia: A meta-analysis. J Clin Anesth 2012;24:639-46. Access this article online Quick Response Code:
Website: www.joacp.org
DOI: 10.4103/0970-9185.130130
Incidental finding of organized thrombus in right inferior pulmonary vein extending in left atrium in the patient scheduled for esophagectomy: What should an anesthesiologist look for? Sir, The extent of investigations in the preoperative period is always controversial. Many investigations are performed as a part of anesthesia work up. Also, investigations are required for surgical work up which may be different from the preanesthetic work up. At times, investigations for surgical work up may give us some important findings which are otherwise missed as happened in our case. The presence of asymptomatic incidental thrombus in a major pulmonary vessel extending in the left atrium could be catastrophic in the patient undergoing thoracic oncologic surgery.[1,2] We report a case of carcinoma esophagus scheduled for esophagectomy in which a thrombus in the right inferior pulmonary vein extending into the left atrium was observed incidentally in contrast enhanced computed tomographic (CECT) scan done for assessing the tumor status of the esophagus by the surgeons. A 58-year-old male patient was diagnosed as carcinoma esophagus and scheduled for transthoracic esophagectomy. The patient denied any other comorbidity except related to carcinoma esophagus. He had received five sessions of radiotherapy one month back. His vitals, cardio-respiratory system examination was normal. The chest X-ray and echocardiography was reported normal. On CECT, apart from the presence of mass in the esophagus, filling defect in the right inferior pulmonary vein that extended into the left
atrium and measuring 19 × 13 mm suggestive of a thrombus was observed. In discussion with radiologist and cardiologist, it was affirmed that the clot was present on the posterior wall of left atrium extending in pulmonary vein which appeared organized and did not causes any compromise in the left atrium outflow. In view of an organized thrombus, as per discussion with cardiologist, we did not start with anticoagulation or any other intervention preoperatively. The patient was premedicated with oral midazolam (7.5 mg) and intramuscular glycopyrrolate (0.2 mg) in the morning of surgery. In the operating room, standard monitors were attached; epidural catheter was placed at T10-11 level. General anesthesia was induced and maintained as per standard protocol and airway secured with double lumen tube. Radial artery and central venous catheters were inserted for invasive monitoring. Intraoperatively, there were multiple episodes of desaturation, especially during the lung retractor application. These were managed with transient release of retractors’ and application of positive end-expiratory pressure (PEEP) and continuous positive airway pressure (CPAP). Beside this episode no major intraoperative event occurred. At the end of surgery, residual neuromuscular blockade was reversed, trachea extubated and the patient was shifted to intensive care unit for further management. In the ICU at 24 h, the patient developed episode of paroxysmal supraventricular tachycardia that was managed with diltiazem. Thereafter, the patient remained hemodynamically stable. The presence of thrombus was an incidental finding in our case. The diagnosis of the left atrial thrombus is usually made on echocardiography. The organized left atrial thrombus may be missed in the echocardiography as happened in our case.[3] Such thrombus can embolize during the surgical manipulations leading to ischemia, destauration and hemodynamic instability.[2,3] Retractor application can reduce cardiac output and subsequently arterial oxygen saturation. The etiology of such events remains a clinical dilemma, if proper diagnosis cannot be established in time.[2] However, sophisticated investigations like CECT are not routinely performed especially when the patient is not symptomatic. Therefore, besides routine work up anesthesiologist involved in the conduct of such cases should also look for the serial investigations performed for the diagnostic purposes. Thorough evaluation of these investigations may provide us with the clues which could be a concern for the patient management and may affect the perioperative outcome. Presence of asymptomatic clot in a major pulmonary vessel extending into the left atrium is a rare finding and can easily be missed on routine investigation. The incidence of
Journal of Anaesthesiology Clinical Pharmacology | April-June 2014 | Vol 30 | Issue 2
301
Letters to Editor
postoperative arrhythmias related to an esophagectomy is 13-64% and this is further aggravated by atrial or pulmonary vein inflammation.[4,5] The presence of organized thrombus in our patient possibly lead to inflammation and perioperative arrhythmias. The presence of thrombus in the heart after a myocardial infarction requires anticoagulation but there are no recommendations for anticoagulation for an organized atrial thrombus in absence of history of myocardial infarction or atrial fibrillation.[6] To conclude, presence of asymptomatic clot should be taken seriously and the possibility of all the complications which can arise should be discussed preoperatively and measures to treat those complications should be available before anesthetizing such patients. Rakesh Garg1, Alka Bhatnagar2, Sushma Bhatnagar3, Seema Mishra4 1 Assistant Professor, 2Senior Resident, 3Additional Professor and Head, 4Additional Professor, Department of Anaesthesiology, Pain and Palliative Care, Dr. BRAIRCH, All India Institute of Medical Sciences, New Delhi, India
Address for correspondence: Dr. Rakesh Garg, 35, DDA Flats, East Punjabi Bagh, New Delhi - 110 026, India. E-mail: [email protected]
References 1.
2.
3. 4. 5.
6.
Agmon Y, Khandheria BK, Gentile F, Seward JB. Clinical and echocardiographic characteristics of patients with left atrial thrombus and sinus rhythm: Experience in 20 643 consecutive transesophageal echocardiographic examinations. Circulation 2002;105:27-31. Alexander GR, Reddi A, Reddy D. Idiopathic pulmonary vein thrombosis: A rare cause of massive hemoptysis. Ann Thorac Surg 2009;88:281-3. Cipriano PR, Guthaner DF. Organized left atrial mural thrombus demonstrated by coronary angiography. Am Heart J 1978;96:166-9. Hahm TS, Lee JJ, Yang MK, Kim JA. Risk factors for an intraoperative arrhythmia during esophagectomy. Yonsei Med J 2007;48:474-9. Ma JY, Wang Y, Zhao YF, Wu Z, Liu LX, Kou YL, et al. Atrial fibrillation after surgery for esophageal carcinoma: Clinical and prognostic significance. World J Gastroenterol 2006;12:449-52. European Heart Rhythm Association; European Association for Cardio-Thoracic Surgery, Camm AJ, Kirchhof P, Lip GY, Schotten U, et al. Guidelines for the management of atrial fibrillation: The task force for the management of atrial fibrillation of the European Society of Cardiology (ESC). Eur Heart J 2010;31:2369. Access this article online Quick Response Code:
Website: www.joacp.org
DOI: 10.4103/0970-9185.130133
302
The fatigued anesthesiologist: Improve operating room climate to minimize effect of residual anesthetics Sir, We read with interest “The fatigued Anesthesiologist: A threat to patient safety?” by Sinha et al.[1] Authors have highlighted in detail professional hazards of prolonged working hours. It is noteworthy that anesthesiology organizations have come forward with strategies to cope up with sleepiness and other fatigue management plans to ensure patient safety. Editorial “Maximum working hours and minimum monitoring standardsneed for both to be mandatory”[2] further enlightens us with the methods to improve attention span of the anesthesiologists by optimizing working hours per day/per week. We wish to emphasize upon the need of scavenging facilities in the operating rooms. Exhaustion after day’s work is directly proportional to the operating room environment, surgery proposed, type of anesthesia required, physical status of the patient and anesthesia equipment used. Tankó et al.[3] used volatile anesthetic absorbers to detect amount of sevoflurane absorbed during intracerebral surgery. Authors reported that absorbers placed in the proximity of patient’s breathing zone captured maximum amount of sevoflurane (1.54 ± 0.55 parts per million [ppm]), followed by the detectors placed near the anesthesiologist (1.14 ± 0.43 ppm). Surgeon’s exposure to volatile anesthetics was six-fold less compared to the anesthesiologist. (0.15 ± 0.05 ppm). This observation of different risk stratification according to professional work have been recently verified in a study by Zaffina et al.,[4] where multi-point sampling method for environmental monitoring was used. To minimize exposure to inhalational anesthetics use of double masks or anesthesia hoods has been suggested.[5,6] Alternatively, use of Total Intravenous Anesthesia or regional anesthesia techniques (wherever feasible) should be encouraged.[7] However, these issues have not been widely addressed in pediatric OR and literature from developing countries is scanty.[8,9] In 1999, Marsh et al.[10] conducted a postal survey of consultant Pediatric Anesthetists to find out anesthesia and scavenging techniques used in neonates, infants and older children (less than 20 kg). Authors reported that T-Piece remains the commonest breathing system used in smaller children and 60% respondents of survey used scavenging system with T-piece. Thus, an anesthesiologist working in a poorly ventilated pediatric operating room (OR) with open/semi-open anesthesia circuit and no scavenging facilities is more likely to be exposed to waste gas residues
Journal of Anaesthesiology Clinical Pharmacology | April-June 2014 | Vol 30 | Issue 2
Copyright of Journal of Anaesthesiology Clinical Pharmacology is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
Zhang X, Chen M, Li Q. The ProSeal Laryngeal Mask Airway is more effective than the LMA-Classic in pediatric anesthesia: A meta-analysis. J Clin Anesth 2012;24:639-46. Access this article online Quick Response Code:
Website: www.joacp.org
DOI: 10.4103/0970-9185.130130
Incidental finding of organized thrombus in right inferior pulmonary vein extending in left atrium in the patient scheduled for esophagectomy: What should an anesthesiologist look for? Sir, The extent of investigations in the preoperative period is always controversial. Many investigations are performed as a part of anesthesia work up. Also, investigations are required for surgical work up which may be different from the preanesthetic work up. At times, investigations for surgical work up may give us some important findings which are otherwise missed as happened in our case. The presence of asymptomatic incidental thrombus in a major pulmonary vessel extending in the left atrium could be catastrophic in the patient undergoing thoracic oncologic surgery.[1,2] We report a case of carcinoma esophagus scheduled for esophagectomy in which a thrombus in the right inferior pulmonary vein extending into the left atrium was observed incidentally in contrast enhanced computed tomographic (CECT) scan done for assessing the tumor status of the esophagus by the surgeons. A 58-year-old male patient was diagnosed as carcinoma esophagus and scheduled for transthoracic esophagectomy. The patient denied any other comorbidity except related to carcinoma esophagus. He had received five sessions of radiotherapy one month back. His vitals, cardio-respiratory system examination was normal. The chest X-ray and echocardiography was reported normal. On CECT, apart from the presence of mass in the esophagus, filling defect in the right inferior pulmonary vein that extended into the left
atrium and measuring 19 × 13 mm suggestive of a thrombus was observed. In discussion with radiologist and cardiologist, it was affirmed that the clot was present on the posterior wall of left atrium extending in pulmonary vein which appeared organized and did not causes any compromise in the left atrium outflow. In view of an organized thrombus, as per discussion with cardiologist, we did not start with anticoagulation or any other intervention preoperatively. The patient was premedicated with oral midazolam (7.5 mg) and intramuscular glycopyrrolate (0.2 mg) in the morning of surgery. In the operating room, standard monitors were attached; epidural catheter was placed at T10-11 level. General anesthesia was induced and maintained as per standard protocol and airway secured with double lumen tube. Radial artery and central venous catheters were inserted for invasive monitoring. Intraoperatively, there were multiple episodes of desaturation, especially during the lung retractor application. These were managed with transient release of retractors’ and application of positive end-expiratory pressure (PEEP) and continuous positive airway pressure (CPAP). Beside this episode no major intraoperative event occurred. At the end of surgery, residual neuromuscular blockade was reversed, trachea extubated and the patient was shifted to intensive care unit for further management. In the ICU at 24 h, the patient developed episode of paroxysmal supraventricular tachycardia that was managed with diltiazem. Thereafter, the patient remained hemodynamically stable. The presence of thrombus was an incidental finding in our case. The diagnosis of the left atrial thrombus is usually made on echocardiography. The organized left atrial thrombus may be missed in the echocardiography as happened in our case.[3] Such thrombus can embolize during the surgical manipulations leading to ischemia, destauration and hemodynamic instability.[2,3] Retractor application can reduce cardiac output and subsequently arterial oxygen saturation. The etiology of such events remains a clinical dilemma, if proper diagnosis cannot be established in time.[2] However, sophisticated investigations like CECT are not routinely performed especially when the patient is not symptomatic. Therefore, besides routine work up anesthesiologist involved in the conduct of such cases should also look for the serial investigations performed for the diagnostic purposes. Thorough evaluation of these investigations may provide us with the clues which could be a concern for the patient management and may affect the perioperative outcome. Presence of asymptomatic clot in a major pulmonary vessel extending into the left atrium is a rare finding and can easily be missed on routine investigation. The incidence of
Journal of Anaesthesiology Clinical Pharmacology | April-June 2014 | Vol 30 | Issue 2
301
Letters to Editor
postoperative arrhythmias related to an esophagectomy is 13-64% and this is further aggravated by atrial or pulmonary vein inflammation.[4,5] The presence of organized thrombus in our patient possibly lead to inflammation and perioperative arrhythmias. The presence of thrombus in the heart after a myocardial infarction requires anticoagulation but there are no recommendations for anticoagulation for an organized atrial thrombus in absence of history of myocardial infarction or atrial fibrillation.[6] To conclude, presence of asymptomatic clot should be taken seriously and the possibility of all the complications which can arise should be discussed preoperatively and measures to treat those complications should be available before anesthetizing such patients. Rakesh Garg1, Alka Bhatnagar2, Sushma Bhatnagar3, Seema Mishra4 1 Assistant Professor, 2Senior Resident, 3Additional Professor and Head, 4Additional Professor, Department of Anaesthesiology, Pain and Palliative Care, Dr. BRAIRCH, All India Institute of Medical Sciences, New Delhi, India
Address for correspondence: Dr. Rakesh Garg, 35, DDA Flats, East Punjabi Bagh, New Delhi - 110 026, India. E-mail: [email protected]
References 1.
2.
3. 4. 5.
6.
Agmon Y, Khandheria BK, Gentile F, Seward JB. Clinical and echocardiographic characteristics of patients with left atrial thrombus and sinus rhythm: Experience in 20 643 consecutive transesophageal echocardiographic examinations. Circulation 2002;105:27-31. Alexander GR, Reddi A, Reddy D. Idiopathic pulmonary vein thrombosis: A rare cause of massive hemoptysis. Ann Thorac Surg 2009;88:281-3. Cipriano PR, Guthaner DF. Organized left atrial mural thrombus demonstrated by coronary angiography. Am Heart J 1978;96:166-9. Hahm TS, Lee JJ, Yang MK, Kim JA. Risk factors for an intraoperative arrhythmia during esophagectomy. Yonsei Med J 2007;48:474-9. Ma JY, Wang Y, Zhao YF, Wu Z, Liu LX, Kou YL, et al. Atrial fibrillation after surgery for esophageal carcinoma: Clinical and prognostic significance. World J Gastroenterol 2006;12:449-52. European Heart Rhythm Association; European Association for Cardio-Thoracic Surgery, Camm AJ, Kirchhof P, Lip GY, Schotten U, et al. Guidelines for the management of atrial fibrillation: The task force for the management of atrial fibrillation of the European Society of Cardiology (ESC). Eur Heart J 2010;31:2369. Access this article online Quick Response Code:
Website: www.joacp.org
DOI: 10.4103/0970-9185.130133
302
The fatigued anesthesiologist: Improve operating room climate to minimize effect of residual anesthetics Sir, We read with interest “The fatigued Anesthesiologist: A threat to patient safety?” by Sinha et al.[1] Authors have highlighted in detail professional hazards of prolonged working hours. It is noteworthy that anesthesiology organizations have come forward with strategies to cope up with sleepiness and other fatigue management plans to ensure patient safety. Editorial “Maximum working hours and minimum monitoring standardsneed for both to be mandatory”[2] further enlightens us with the methods to improve attention span of the anesthesiologists by optimizing working hours per day/per week. We wish to emphasize upon the need of scavenging facilities in the operating rooms. Exhaustion after day’s work is directly proportional to the operating room environment, surgery proposed, type of anesthesia required, physical status of the patient and anesthesia equipment used. Tankó et al.[3] used volatile anesthetic absorbers to detect amount of sevoflurane absorbed during intracerebral surgery. Authors reported that absorbers placed in the proximity of patient’s breathing zone captured maximum amount of sevoflurane (1.54 ± 0.55 parts per million [ppm]), followed by the detectors placed near the anesthesiologist (1.14 ± 0.43 ppm). Surgeon’s exposure to volatile anesthetics was six-fold less compared to the anesthesiologist. (0.15 ± 0.05 ppm). This observation of different risk stratification according to professional work have been recently verified in a study by Zaffina et al.,[4] where multi-point sampling method for environmental monitoring was used. To minimize exposure to inhalational anesthetics use of double masks or anesthesia hoods has been suggested.[5,6] Alternatively, use of Total Intravenous Anesthesia or regional anesthesia techniques (wherever feasible) should be encouraged.[7] However, these issues have not been widely addressed in pediatric OR and literature from developing countries is scanty.[8,9] In 1999, Marsh et al.[10] conducted a postal survey of consultant Pediatric Anesthetists to find out anesthesia and scavenging techniques used in neonates, infants and older children (less than 20 kg). Authors reported that T-Piece remains the commonest breathing system used in smaller children and 60% respondents of survey used scavenging system with T-piece. Thus, an anesthesiologist working in a poorly ventilated pediatric operating room (OR) with open/semi-open anesthesia circuit and no scavenging facilities is more likely to be exposed to waste gas residues
Journal of Anaesthesiology Clinical Pharmacology | April-June 2014 | Vol 30 | Issue 2
Copyright of Journal of Anaesthesiology Clinical Pharmacology is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
