During thoracic anaesthesia and in postoperative care, it is necessary to monitor haemodynamic status, especially in high-risk patients. Although the Swan–Ganz catheter is considered the gold standard advanced haemodynamic monitor, right now there is no consensus on the optimal haemodynamic monitoring method in thoracic anaesthesia for high-risk patients. We intend to present a method [the pulse contour cardiac output–volumetric ejection fraction monitoring system (PiCCO–VoLEF); Pulsion Medical Systems, Munich, Germany], which we used during thoracic anaesthesia for a patient who was to undergo heart transplantation.
A 45-year-old woman, a candidate for heart transplantation, had had previous history of hypertension, insulin-dependent diabetes mellitus (IDDM) and myocardial infarction and had undergone three-vessel coronary artery stenting as well as implantable cardioverter defibrillator (ICD) implantation. During her preoperative evaluation for heart transplantation, a tumour, 19 mm in diameter, was found in her right lung. Subsequently, a thoracoscopic partial lung resection was planned in order to verify the nature of the tumour.
Perioperative assessment and preparation
From among the preoperative evaluation results, we intend to highlight the results of echocardiography, exercise test and invasive haemodynamical measurement.
Echocardiography revealed a second to third degree mitral insufficiency and tricuspidal insufficiency, dilated left ventricle and atrium, diffuse hypokinesis and akinesis, a 60 mmHg right ventricular systolic pressure and a 15% ejection fraction. In dobutamine stress echocardiography combined with the Swan–Ganz catheter, no viability was seen at the myocardium after stent implantation, but chronotropic incompetence and improvement in the heart function were present.
The day before surgery, a VoLEF pulmonary catheter (PV2047, VoLEF Catheter PACC 947, Pulsion Medical Systems) was inserted via the right internal jugular vein into the right pulmonary artery under the guidance of flouroscopy. Because the VoLEF pulmonary catheter has no shield, of its own, we used the standard pulmonary artery catheter shield (Catheter Contamination Shield 80 cm, Edwards Lifesciences, Irvine, California, USA). After catheter fixation, we inserted a PiCCO catheter (PV2015L20A, Pulsiocath; Pulsion Medical Systems) into the right femoral artery and performed the baseline measurements. For haemodynamic monitoring, we used a combination of PiCCO Plus V 5.2.2 and VoLEF V 1.0 (Pulsion Medical System) monitors.
On the morning of the surgery, we switched the ICD to pacemaker mode via telemetry.
At the time of skin incision, one-lung ventilation (OLV) was started with a fiO2 of 100%. The surgical plan was originally a video-assisted thoracoscopic surgery (VATS), but due to adhesions caused by previous pneumonias, intraoperatively, an open thoracotomy was decided. At 15 min of OLV, the pulmonary vascular resistance (PVR) increased, tachycardia and then bradycardia developed, and then the SatO2, pulmonary artery pressure (PAP) and cardiac output (CO) decreased and central venous pressure (CVP) increased. We immediately started and continued double-lung ventilation until the end of surgery and the administration of dobutamine, norepinephrine and the infusion rate was increased. The above parameters were normalized in a few minutes. The remaining part of the surgery was uneventful and we were able to decrease the dose of dobutamine and norepinephrine. The surgeons performed the resection of the eighth segment of the right lung. After completion of the surgery, we changed the double-lumen tube (DLT) to a single-lumen tube and transported the patient to the ICU under sedation and mechanical ventilation.
In the ICU, we omitted norepinephrine and gradually decreased the dose of dobutamine. In the sixth postoperative hour, we could extubate the patient and switched the ICD on. On the third postoperative day, we omitted dobutamine and on the fourth day, we removed the haemodynamic catheters and the chest tubes; the patient was admitted to the ward and on the tenth postoperative day, the patient left the hospital. The results of haemodynamic monitoring during the perioperative period are shown in Fig. 1.
We were facing hard pathophysiological conditions and we chose a monitor that enabled us to meet the monitoring requirements. The underlying conditions that we had to face were as follows:
- Left and right heart failure and dilation, tricuspidal and mitral regurgitation, elevated right ventricular and pulmonary arterial pressure, ICD in situ: as mitral and tricuspidal regurgitation caused dilated pulmonary vessels, we found the wedge-position very peripheral (60 cm). Additionally, we had to avoid knotting of the long pulmonary catheter and the ICD electrode inside the heart during insertion. Fortunately, the VoLEF pulmonary catheter is radiopaque and 110 cm long, so under fluoroscopic guidance, the positioning of the catheter to the correct place became possible.
- Hypoxic pulmonary vasoconstriction: if alveolar oxygen tension falls below 60 mmHg, hypoxic pulmonary vasoconstriction occurs. This vasoconstriction is a significant afterload for the right ventricle, especially if it is impaired. An acute elevation of the afterload causes a dilatation of the impaired right ventricle and the interventricular septum is shifted towards the left ventricle, resulting in a decrease in the diastolic filling of the left ventricle. This decreased left ventricular filling leads to a decrease in CO and a consequent collapse of the circulation. The PiCCO–VoLEF monitor enabled us to measure PVR, right ventricular ejection fraction (RVEF), the ratio of the right and left heart (R/L), the right heart and left heart end-diastolic volume (RHEDV, LHEDV) and PAP. With the help of this monitor, the diagnosis and the immediate treatment of the left and right heart failure became possible. One of the most important parameters of systemic circulation for us was systemic vascular resistance (SVR), because the patient had mitral insufficiency in her previous history and we had to secure optimal vascular resistance both because of the left ventricle and because of the previous mitral insufficiency. In order to decrease PAP, we used dobutamine and we compensated for its systemic vasodilatory effect with norepinephrine. Optimization of SVR increased the left ventricular filling, because it pushed the interventricular septum back towards the right ventricle. In contrast to this, an elevated SVR would increase the regurgitant blood volume to the left atrium and would decrease CO [1–6].
- Increased blood flow in the lung (fluid overload): after pulmonary resection, sometimes acute lung injury (ALI) and pulmonary oedema may occur. The origin of this oedema is complex and not entirely clear: surgical manipulation, fluid overload, damage to the alveolar-capillary barrier from mechanical ventilation and the reexpansion of the lung are all implicated. With the use of the PiCCO–VoLEF monitor, one can identify the pulmonary oedema by measuring extravascular lung water (EVLW). The use of this monitoring technique helps to differentiate between the oedemas of different origins; if the pulmonary vascular permeability index (PVPI) is below 3, the oedema is most probably of cardiac or hydrostatic origin and if the PVPI is greater than 3, the origin of the oedema is postresectional ALI/adult respiratory distress syndrome (ARDS). The use of this monitoring technique also enables us to guide fluid therapy according to needs [7,8].
During thoracic anaesthesia for high-risk patients, the anaesthesiologist has to know the pressure of the pulmonary vascular system, the left/right and global heart functions and the EVLW/PVPI. These parameters can be measured separately with pulmonary artery catheter and a PiCCO monitor, but the combined use of the PiCCO–VoLEF monitor makes it possible for the anaesthesiologist to use only one system.
1 Waller AD, Keavey P, Woodfine L, Dark JHl. Pulmonary endothelial permeability changes after major lung resection. Ann Thorac Surg 1996; 61:1435–1440.
2 Della Rocca G, Costa MG. Preload indexes in thoracic anesthesia. Curr Opin Anaesthesiol 2003; 16:69–73.
3 Della Rocca G, Costa MG. Hemodynamic-volumetric monitoring. Minerva Anesthesiol 2004; 70:229–232.
4 Della Rocca G, Costa GM, Coccia C, et al
. Preload index: pulmonary artery occlusion pressure versus intrathoracic blood volume monitoring during lung transplantation. Anesth Analg 2002; 95:835–843.
5 Chiu CL, Mansor M, Majid A. Anaesthetic management of high-risk cardiac patients undergoing thoracic surgery with the support of intra-aortic balloon pump. Br J Anaesth 2005; 94:688–689.
6 Roch A, Michelet P, D'journo B, et al
. Accuracy and limits of transpulmonary dilution methods in estimating extravascular lung water after pneumonectomy. Chest 2005; 128:927–933.
7 Monnet X, Anguel N, Osman D, et al
. Assessing pulmonary permeability by transpulmonary thermodilution allows differentiation of hydrostatic pulmonary edema from ALI/ARDS. Intensive Care Med 2007; 33:448–453.
8 Slinger P. Fluid management during pulmonary resection surgery. Ann Cardiac Anaesth 2002; 5:220–224.