(Acta Anaesth. Belg., 2017, 68, 39-41) Should ECPR be attempted following refractory cardiac arrest secondary to airway obstruction by a mediastinal mass?

I. Azher, D. Buggy and E. Carton

Abstract : Mediastinal masses may compress the heart, edema with engorgement of superficial veins in the large blood vessels (particularly the superior vena cava), upper thorax and neck. He also reported some recent the trachea or major bronchi leading to abrupt collapse. fatigue and weight loss but denied any dyspnea or Even patients who are relatively asymptomatic while orthopnea. awake can develop acute respiratory or hemodynamic On examination, the patient was alert, in collapse after induction of general anesthesia. We present a no respiratory distress and Pemberton’s sign patient who developed total airway occlusion and cardiac arrest after induction of general anesthesia. Management (congestion and cyanosis of the face with increased included urgent deployment of peripheral veno-arterial respiratory distress when both arms are elevated (VA) extracorporeal membrane oxygenation for against the side of the head) was negative. There continued extracorporeal cardiopulmonary resuscitation were no palpable lymph nodes in the neck or axillae. (ECPR). Thoracic computed tomography (CT) revealed Deployment of peripheral VA extracorporeal support a large mediastinal mass causing partial obstruction may have eventually restored hemodynamic stability to the SVC and narrowing of the distal trachea. A in this patient but the pre-induction deployment of radiology guided percutaneous biopsy of the mass extracorporeal support would have provided much more was considered too high-risk and the patient was effective brain perfusion. We should be cautious about referred to our cardio-thoracic surgeons for surgical attempting to deploy extracorporeal support after an opinion. A limited anterior thoracotomy rather than acute collapse in a patient with a mediastinal mass and where conventional chest compressions and attempts at a mediastinoscopy was planned because of the soft ventilation may not provide satisfactory brain perfusion tissue swelling in the neck. or oxygenation. Following a review of the CT images with the surgeon, it was decided that optimal tissue samples Key words : ECPR ; ECMO ; mediastinal mass. could be acquired through a small left sided anterior thoracotomy under general anesthesia. There was some urgency to proceed with the biopsy so that the Introduction most appropriate chemotherapy could be initiated without delay. A large mediastinal mass can compress the Routine monitors were applied and general heart, superior vena cava (SVC), trachea or major anesthesia was induced with propofol and fentanyl. bronchi during a diagnostic or surgical procedure. After establishing that spontaneous ventilation Even patients who are relatively asymptomatic could be easily assisted by manual face mask while awake can develop abrupt collapse during positive pressure ventilation, atracurium was used general anesthesia (1). We present a patient sche- to facilitate tracheal intubation. duled for surgical biopsy of a mediastinal mass who It was immediately evident that manual venti- developed total airway occlusion and cardiac arrest lation of the lungs required high airway pressure after induction of general anesthesia. Management associated with an upward sloping expiratory included urgent deployment of extracorporeal capnograph trace. There was progressive difficulty cardiopulmonary resuscitation (ECPR) for refrac- with manual ventilation of the lungs with no end- tory cardiac arrest.

Imran Azher, M.D. ; Donal Buggy, Prof. ; Ed Carton, M.D. Case Rep ort Division of Anaesthesia, Mater University Hospital, School of Medicine, University College, Dublin, Ireland A 17 year old previously healthy male Correspondence address : Azher I., Department of Anaesthesia and Critical Care, Mater Misericordiae University Hospital, patient presented for surgical biopsy of an anterior Eccles St, Dublin 7, Ireland. mediastinal mass. He had a two-week history of E-mail : [email protected]

© Acta Anæsthesiologica Belgica, 2017, 68, n° 1 40 i. azher et al. tidal carbon dioxide signal recorded. After a first anesthesia in a patient with a large mediastinal endo-tracheal tube insertion and evidence of no mass. It also highlights that even if ECPR can be efficient mechanical ventilation, the endo-tracheal deployed rapidly, there is a real risk of the patient tube was replaced. There was no evidence of sustaining a hypoxic brain injury. obstruction of the original tube but the inability to Tissue biopsy of a mediastinal mass should ventilate the lungs remained unchanged. Multiple be carried out using the least invasive method. attempts were made to improve ventilation by re- Needle biopsy using local anesthesia in an awake, positioning the patient to the right and left lateral spontaneously breathing patient in the slightly head- and sitting-up position but ventilation of the up position with CT or ultrasound (US) guidance lungs remained impossible. Rigid bronchoscopy has been well described. Anterior mediastinoscopy confirmed extrinsic compression of the distal and biopsy under local anesthesia or US-guided trachea, but it was not possible to advance the rigid aspiration of pleural fluid can lead to a definitive scope past the obstruction. Hypoxic cardiac arrest diagnosis. occurred 15 minutes after induction of anesthesia In patients with a mediastinal mass presenting and conventional cardiopulmonary resuscitation for a surgical procedure, there should be a high (CPR) was established immediately. index of suspicion that abrupt collapse may occur Because of the failure to respond to conven- even in previously asymptomatic patients. tional CPR, we decided to attempt ECPR. During Pre-operative assessment includes a history and ongoing chest compressions, the femoral artery clinical examination for evidence of compression and vein were cannulated and peripheral veno- of the SVC (edema or distension of the superficial arterial extracorporeal life support (VA ECLS) was veins in the upper body and neck) or the airway established 15 minutes after the cardiac arrest. There (dyspnea, stridor, syncope) and in particular, if there was a rapid increase in arterial oxygen saturation is a postural component to symptoms1. with reversal of the shock sate and both pupils Thoracic CT images should be reviewed to were noted to respond to light. We proceeded with assess the location of the mass and the degree of biopsy of the mediastinal mass and histological associated vascular or airway compression. Pre- examination indicated an un-differentiated T-cell operative echocardiography is indicated if there lymphoma. is evidence of compression of the heart or in the The patient was transferred to the Intensive presence of a pericardial effusion. Flow volume Care Unit (ICU) with VA ECLS and high dose loops have been used to document intra-thoracic chemotherapy was started that evening. There was airflow obstruction, but do not add significantly to a reduction in the size of the mediastinal mass over the information obtained with chest imaging (2). the next 10 days and it was possible to wean off VA Patients should be considered at high risk of ECLS without difficulty. peri-operative complications if they have severe During the first week in ICU, the patient was postural symptoms, stridor, cyanosis, have > slow to wake up although he did open his eyes 50% decrease in the cross-sectional area of the to voice and withdraw his upper limbs to painful trachea, have evidence of bronchial compression in stimuli. Magnetic resonance imaging of the brain association with tracheal compression or evidence did not show definite features of hypoxic ischemic of SVC compression or pericardial effusion (1). brain injury. During the second and third week in If general anesthesia is being considered for ICU, there was no improvement in his neurological a patient with a mediastinal mass, a pre-operative status and no sign of marrow recovery. Despite multidisciplinary meeting is essential to discuss the broad-spectrum antimicrobial therapy, the patient procedure and plan any additional interventions that developed repeated episodes of gram negative may be required. A clinician skilled in fiberoptic and bacterial and fungal sepsis with progressive pulmo- rigid bronchoscopy should be immediately available nary and renal failure. Twenty-eight days after ICU along with a range of reinforced endotracheal tubes. admission, the patient died of neutropenic sepsis. In carefully selected cardiac arrest patients who remain unresponsive to conventional cardio- pulmonary resuscitation, ECPR is being used Discussion successfully3. The indications for ECPR include a potentially reversible or treatable cause for the Our case report highlights the risk of abrupt cardiac arrest (acute myocardial infarction, hypo- and complete distal airway obstruction leading to thermia, cardiac drug intoxication), the ability to refractory cardiac arrest after induction of general deploy ECLS within 60 minutes of the collapse and

© Acta Anæsthesiologica Belgica, 2017, 68, n° 1 ecpr by a mediastinal mass 41 the provision of high quality conventional CPR from support can be instituted without delay after airway the time of the arrest. Contraindications to ECPR obstruction4. include aortic dissection, severe aortic regurgitation, In conclusion, we present a case report of patients at increased risk of hypoxic brain injury abrupt cardiac arrest after induction of general (un-witnessed cardiac arrest) and patients with a anesthesia in a patient with a mediastinal mass. definite contra-indication to anti-coagulation. All conventional resuscitation measures were Many authors have warned about the dangers ineffective. of ‘stand-by’ cardiopulmonary bypass (CPB) or Deployment of ECPR may have restored ECLS deployed after refractory cardiac arrest in early hemodynamic stability and facilitated a patients with a mediastinal mass (2,4). chemotherapy-induced decrease in the vascular and The time from the collapse to the decision to airway compression by the tumor mass. However, request extracorporeal support and the time from the time required to institute ECPR and restore brain that call to starting extracorporeal blood flow is perfusion and oxygenation may have contributed likely to be prolonged even with ready access to to poor neurological outcome. In our view, there an experienced team and rapid uncomplicated should be no place for ECPR in patients with a deployment of ECLS. It is also likely that closed mediastinal mass after refractory cardiac arrest. chest compressions in a patient with a mediastinal mass may increase the degree of vascular or airway obstruction so that the quality of brain perfusion and References oxygenation during this protracted period may not 1. Blank RS, deSouza DG. Anesthetic management of patients be optimal. with an anterior mediastinal mass. Can. J. Anesth., 8, 853- If delayed attempts to deploy CPB or ECLS 67, 2011. 2. Slinger P, Karsil C. Management of the patient with a large after cardiac arrest in these patients are associated anterior mediastinal mass: recurring myths. Curr. Opin. with an increased risk of hypoxic brain injury, the Anaesthesiol., 20, 1-3, 2007. same arguments should apply to ECPR. Despite 3. Stub D, Bernard S, Pellegrino V, et al. Refractory cardiac our best efforts, institution of ECPR in the present arrest treated with mechanical CPR, hypothermia, ECMO and early reperfusion (the CHEER trial). Resuscitation, 86, case report did take some time and this may have 88-94, 2015. contributed to the limited neurological recovery. 4. Erdos G, Tzanova I. Perioperative anaesthetic management Pre-operative femoral cannulation under local of mediastinal mass in adults. Eur. J. Anaesthesiol., 26, 627-32, 2009. anesthesia has been described so that extracorporeal

© Acta Anæsthesiologica Belgica, 2017, 68, n° 1