PURPOSE: The prone position is required for posterior spinal fusion surgery and may be associated with cardiovascular changes, including a decrease in venous return and cardiac index. We report a case of a patient who developed cardiovascular collapse, increased central venous pressure (CVP), and massive bleeding during posterior spinal fusion surgery. A transesophageal echocardiography examination (TEE) documented a right ventricular outflow tract (RVOT) obstruction associated with the use of transverse bolsters. CLINICAL FEATURES: We describe a case of a healthy 14-yr-old male with idiopathic scoliosis who developed severe intraoperative cardiovascular instability and massive bleeding. The surgery was suspended, and the patient was transferred to the intensive care unit. The patient subsequently underwent TEE in the supine and prone positions. The echocardiogram appeared normal in the supine position; however, in the prone position with transverse bolsters, we identified a significant decrease in the diameter of the RVOT that worsened with pressure applied against the thoracic spine. The central venous pressure increased from 10-24 mmHg simultaneously. We found appreciably less impact to the RVOT, RV size and flow, and CVP (10 to 14 mmHg) using longitudinal bolsters both with and without pressure to the back. This position was recommended for the patient's reoperation, which was uneventful. CONCLUSION: A TEE confirmed a RVOT obstruction in the prone position that was associated, in this case, with the use of transverse bolsters. The RVOT obstruction was explained by the chest deformity, compliant chest cage, bolstering, and pressure applied to the patient's back by the surgeon. This positional RVOT obstruction may explain the increase in the CVP and the secondary massive bleeding during the first operation. The TEE was useful to diagnose the patient's condition and to guide his positioning for the second operation.
PURPOSE: The prone position is required for posterior spinal fusion surgery and may be associated with cardiovascular changes, including a decrease in venous return and cardiac index. We report a case of a patient who developed cardiovascular collapse, increased central venous pressure (CVP), and massive bleeding during posterior spinal fusion surgery. A transesophageal echocardiography examination (TEE) documented a right ventricular outflow tract (RVOT) obstruction associated with the use of transverse bolsters. CLINICAL FEATURES: We describe a case of a healthy 14-yr-old male with idiopathic scoliosis who developed severe intraoperative cardiovascular instability and massive bleeding. The surgery was suspended, and the patient was transferred to the intensive care unit. The patient subsequently underwent TEE in the supine and prone positions. The echocardiogram appeared normal in the supine position; however, in the prone position with transverse bolsters, we identified a significant decrease in the diameter of the RVOT that worsened with pressure applied against the thoracic spine. The central venous pressure increased from 10-24 mmHg simultaneously. We found appreciably less impact to the RVOT, RV size and flow, and CVP (10 to 14 mmHg) using longitudinal bolsters both with and without pressure to the back. This position was recommended for the patient's reoperation, which was uneventful. CONCLUSION: A TEE confirmed a RVOT obstruction in the prone position that was associated, in this case, with the use of transverse bolsters. The RVOT obstruction was explained by the chest deformity, compliant chest cage, bolstering, and pressure applied to the patient's back by the surgeon. This positional RVOT obstruction may explain the increase in the CVP and the secondary massive bleeding during the first operation. The TEE was useful to diagnose the patient's condition and to guide his positioning for the second operation.
Authors: Yu Hao Zeng; Alexander Calderone; Nicolas Rousseau-Saine; Mahsa Elmi-Sarabi; Stéphanie Jarry; Étienne J Couture; Matthew P Aldred; Jean-Francois Dorval; Yoan Lamarche; Lachlan F Miles; William Beaubien-Souligny; André Y Denault Journal: CJC Open Date: 2021-04-09