Rev. Bras. Anestesiol. vol.64 número3

RevBrasAnestesiol.2014;64(3):199---200

REVISTA

BRASILEIRA

DE

ANESTESIOLOGIA

CLINICAL

INFORMATION

Inferior

venacaval

compression

due

to

excessive

abdominal

packing

M.C.B.

Santhosh

,

Rohini

Bhat

Pai

,

Roopa

Sachidanand

,

Varun

Byrappa

,

Raghavendra

P.

Rao

a_{DepartmentofAnaesthesiology,ShriDharmasthalaManjunatheshwaraCollegeofMedicalSciencesandHospital,Dharwad,}

Karnataka,India

b_{DepartmentofAnaesthesiology,KarnatakaInstituteofMedicalSciences,Hubli,Karnataka,India}

Received30January2013;accepted22March2013

Availableonline16October2013

KEYWORDS

Inferiorvenacaval compression; Abdominalpacking; Intraabdominal surgery

Abstract Inferiorvenacavalcompressionisacommonprobleminlatepregnancy.Itcanalso occurduetocompressionofinferiorvenacavabyabdominalorpelvictumors.Wereportacase ofacuteiatrogenicinferiorvenacavalcompressionduetoexcessiveabdominalpackingduring anintraabdominalsurgery.

© 2013SociedadeBrasileirade Anestesiologia.Publishedby ElsevierEditoraLtda.Allrights reserved.

Introduction

Inferiorvenacavalcompressionisacommonprobleminlate pregnancy.1 _{It can alsooccur due tocompression of}

infe-riorvenacavabyabdominalorpelvictumors.Acuteinferior venacavalcompression is associatedwithsevere hemody-namic variations. We report a case of acute iatrogenic inferiorvenacavalcompressionduetoexcessiveabdominal packingduringanintraabdominalsurgery.

∗_{Correspondingauthor.}

E-mail:[email protected](M.C.B.Santhosh).

Case

report

A forty-five-year-old male patient with carcinoma head of pancreas wasposted for Whipple’s procedure. He was a well controlled hypertensive on oral metoprolol 25mg oncedaily.Hisefforttolerancewasgood.Hedidnothave anyother coexisting diseaseandallroutineinvestigations includingECG, Echocardiogramwerewithinnormallimits. Hereceivedcombinedepiduralandgeneralanesthesiawith standard monitors including intra-arterial blood pressure andcentralvenouspressure(CVP)monitoring.A20G epidu-ralcatheterwasinsertedatT8-9interlaminarspacewithan 18G Tuohy’s needle before induction of general anesthe-siaandpositionofthecatheterwasconfirmedbyinjecting solutioncontaining 60mg lidocaine and 15␮g adrenaline.

Generalanesthesiawasinducedwithintravenousfentanyl 200␮g, propofol 150mg and trachea wasintubated after

0104-0014/$–seefrontmatter©2013SociedadeBrasileiradeAnestesiologia.PublishedbyElsevierEditoraLtda.Allrightsreserved.

200 M.C.B.Santhoshetal.

achievingneuromuscularblockadewithintravenous vecuro-nium 8mg. Anesthesia was maintained with morphine, oxygen,nitrousoxideandisofluranewithpositivepressure ventilation.Epiduralanesthesiawasinitiatedwith8mLof 0.25%bupivacaineandmaintainedwith0.25%bupivacaine infusionattherateof8mLh−1_{.Thesurgerywasuneventful}

duringthefirsttwointraoperativehourswithanormalheart rate(80---90bpm),blood pressure (110/70---124/82mmHg), EtCO2(33---35mmHg),SPO2(98---99%)andCVP(8---10mmHg).

Inthethirdintraoperativehour,suddenbriskbleedingwas noticedasoneofthetributariesofthesuperiormesenteric vein was accidentally severed and around 100---125mL of blood waslost over 5min. Surgeontried to stop bleeding byligatingthebleedingvesselbutfailed.Soasatemporary measureuntiltheavailabilityofvascular clips, abdominal packingwasdoneatthesiteofbleeding.Immediatelya sud-denfallinheartratefrom80bpmto30bpm,bloodpressure from124/74mmHgto56/34mmHg,CVP from10mmHgto 2mmHgandETCO2from34mmHgto10mmHgwasnoticed.

The pulseoximeter started giving poor signal alarm. ECG did not show any rhythm or ST-T changes. Patient was immediatelyadministeredwithintravenousatropine0.6mg, ephedrine 30mg and rapidly infused with 1000mL ringer lactate(over5min).Even10minafterinitiatingabove mea-sures, there was only a slight increase in heart rate to 44bpm,bloodpressureto70/46mmHg,ETCO2to18mmHg

andCVP to4mmHg.Thepulseoximetercontinuedtogive poorsignalalarm.Asadesperatemeasurethesurgeonwas requestedtoremovetheabdominalpacksfromthebleeding site.Soonaftertheremovalofabdominalpacks,increasein theheartrate,bloodpressureandEtCO2wasobservedwhich

reachednormallevelsinlessthanaminute.Hemostasiswas achievedby applicationofvascular clips.The surgerywas latercompleteduneventfully.Thepostoperativeperiodwas uneventful.

Discussion

Compressionoftheinferiorvenacavaonthevertebral bod-iesbythegraviduterusisseencommonlywhenapregnant woman liessupine which leads to a decrease in the car-diacoutputbecauseof obstructiontothe venousreturn.1

This is manifested asdizziness, nausea,and restlessness. In the pregnant women under general anesthesia, infe-riorvenacavalcompression willpresent withsudden drop in blood pressure, heart rate and end tidal carbon diox-ide level which gets corrected by either left lateral tilt of the gravid uterus or by the rapid extraction of the fetus. Similar acute events have been reported in ortho-pedicpatientsundergoingsurgeryinlateralpositionwhose abdomenwascompressedbytheabdominalpostsupports.2

Our patient,whowas stableduring thefirst two intraop-erativehours,developed suddensevere drop intheblood pressure, heart rate, CVP and ETCO2 soon after packing

overthebleedingsitebythesurgeon.Therewasno signifi-cantclinicalimprovementafteradministrationofatropine, vasopressor and rapid fluid infusion which ruled out the blood loss as the cause of hemodynamic derangement. Insignificant changes in ECGand decreased CVP ruled out cardiac eventandpulmonary embolismaspossible causes ofthehemodynamicderangement.Thoracicepidural anes-thesia administered for this patient was limited to 4---5 segments and also there wasno significant hemodynamic improvement after administration of atropine, ephedrine andintravenousfluidswhich ruledoutthethoracic epidu-ral anesthesiainducedsympatheticblockade asthecause of this abrupt hemodynamic change. The drastic clinical improvementseenaftertheremovalofabdominalpacksby thesurgeonindicatedthatinferiorvencavalcompressionby excessiveabdominalpacking wasthecause for theabove hemodynamic fluctuation. The mechanism of bradycardia associatedwithhypotensionisafallinrightatrialfillingdue toinferiorvenacavalcompression,whichdecreasesoutflow fromintrinsicchronotropicstretchreceptorslocatedinthe rightatriumandgreatveins.3

Conclusion

Theepisodeofsuddenbradycardia,hypotensionandfallin ETCO2wasduetoinferiorvenacavalcompressioncausedby

excessiveabdominalpacking over thebleedingsite which wassupportedbyimprovementintheclinicalconditionsoon aftertheremovalofabdominalpacks.Ifithadgone unno-ticed or uncorrected, it couldhave ledto a catastrophic event.Soanesthesiologistsshouldkeepinmind,the exces-sive abdominal packing asone of the potential causes of inferiorvenacavalcompression.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

References

1.KieferRT,PloppaA,DieterichHJ.Aortocavalcompression syn-drome.Anaesthesist.2003;52:1073---83.

2.SatishaM,EvansR.Venocavalcompressionduetoabdominalpost supportand positioning duringorthopaedicanesthesia. Anaes-thesia.2007;62:1080.