Post thoracotomy cardiorespiratory arrest: Perhaps avoidable?

Sir,

Extensive tumor handling and resection in lung surgeries are associated with an increased incidence of morbidity and mortality. We report a rare life-threatening complication following lung surgery in the immediate postoperative period.

Patient was a diagnosed case of right lung sarcoma scheduled for right pneumonectomy, admitted with the complaints of gradually increasing breathlessness on exertion for 3 months and hemoptysis for 7 days. On performing endoscopic snaring of right bronchial intraluminal mass [Figure 1], patient had symptomatic relief for few days, but the symptoms again recurred. Chest X-ray revealed homogeneous opacity over right middle and lower zone [Figure 2]. Computed tomography chest and positron emission tomography scan findings were suggestive of right lung mass [Figure 3] which was abutting the right cardiac border and encasing the right main bronchus with segmental collapse of the lower lobe. Pulmonary Function Test findings were suggestive of restrictive airway disease. The possibility of inoperability was explained and high-risk informed consent for surgical intervention was obtained. After achieving One Lung Ventilation Left thoracotomy was performed, but tumor could not be removed completely due to the intense adherence of the mass to major vessels, attempts to debulk and relieve the bronchial obstruction were unsuccessful, and thorax was closed after inserting an Inter Costal Drain.

Figure 1

Tumor mass obstructing right main bronchus

Figure 2

Homogenous opacity of right middle and lower zone

Figure 3

Tumor mass abutting major vessel

Due to inadequate spontaneous tidal volume, Double Lumen Tube was replaced with oral EndoTracheal Tube and pressure support ventilation was planned. Patient was shifted to postanesthesia care unit (PACU) with normal hemodynamic parameters but within 10 min of reaching the PACU SpO2, Invasive Blood Pressure decreased rapidly, ventilator showed high airway pressure (Paw >40 cm of H2O). Airway obstruction was suspected as even manual ventilation was difficult. Electrocardiogram showed ventricular fibrillation alongwith absent carotid pulses, necessitating external cardiac massage and defibrillation, with resultant return of spontaneous circulation (ROSC) and sinus rhythm. Fresh blood was observed in the EndoTracheal Tube which was continuing despite suctioning, and tumor bleed was suspected, hence fiberoptic bronchoscopy performed at that time revealed a tumor mass obstructing left main bronchus, and bleeding from the right bronchus. With ongoing resuscitative measures the patient was shifted to the operation theater (OT) and rigid bronchoscopy was performed. On piece meal removal of tumor from left main bronchus, oxygen saturation increased and ionotropes were weaned gradually.

Various causes of hemodynamic instability and cardiac arrest after thoracic surgery are well-documented in the literature such as hemorrhage, cardiac tamponade, cardiac herniation, and tension pneumothorax.[123] Our patient had acute cardiorespiratory arrest within minutes of shifting to postanesthesia care unit; a very high Paw and inability to ventilate manually raised possibility of acute tension pneumothorax or airway obstruction. On the contrary fibreoptic bronchscopy revealed migrated tumor tissue blocking the left main bronchus.

We could diagnose tumor migration only in the postanesthesia care unit; but this migration may have occurred earlier, possibly at the end of surgery or during patient repositioning. We should have performed fiberoptic bronchscopy after changing the Double Lumen Tube to single lumen tube and should have checked the tracheobronchial tree before shifting patient from OT, to avoid this life-threatening complication. We strongly recommend performance of flexible fibreoptic bronchoscopy routinely before and after ET tube change or extubation especially with excessive handling of tumor tissue.