K Ashok1, A Mahalakshmi1, A Hariesh1, A Kalyanaraman1. 1. Department of Cardiothoracic Anaesthesia, SRM Medical College Hospital and Research Centre, Chennai, Tamil Nadu, India.
Sir,Boerhaave's syndrome is a rare and lethal condition involving complete transmural laceration of the oesophagus.[1] It can be difficult to diagnose because there are no classic symptoms, and the perforation can masquerade many clinical conditions such as acute myocardial infarction, tension pneumothorax[2] or pneumoperitoneum. Literature reports a mortality of 100%, if untreated. We report this case to illustrate possible anaesthetic implications of this disease.A 52-year-old male, a known alcoholic presented to us with severe drowsiness, in a state of circulatory shock, 15 h after the onset of projectile vomiting and chest pain. On chest auscultation, left-sided crepitations were present. Haemogram revealed haemoglobin of 9 g/dl and white blood cell count of 11 × 109/L. Electrocardiogram was normal and troponin T was negative. Chest X-ray revealed left lung opacities, blunting of costophrenic angle and pneumomediastinum [Figure 1]. Computed tomography of chest confirmed oesophageal rupture, as there was extravasation of contrast from the distal oesophagus into the mediastinum.
Figure 1
Pre-operative chest X-ray showing left lung opacities, blunting of costophrenic angles and pneumomediastinum
Pre-operative chest X-ray showing left lung opacities, blunting of costophrenic angles and pneumomediastinumThe patient was taken up for surgery within 4 h of admission. Invasive blood pressure (BP) and central venous pressure (CVP) monitoring were initiated, which revealed a BP of 70/50 mm Hg and CVP of 4 mmHg. Arterial blood gas (ABG) analysis revealed severe hypoxia (PO2-63 mmHg on FiO2 0.4) and severe metabolic acidosis (pH 7.12) with elevated lactate (6.67 mmol/L) levels. The patient was receiving dopamine infusion at 8 μ/kg/min. A combination of crystalloid (normal saline 0.9% - 0.5 L) and colloid resuscitation (Voluven™ 6% - 0.3 L) was performed, titrated to a CVP of 10 mmHg. Noradrenaline infusion was started at 0.05 μ/kg/min and titrated to a target mean arterial pressure of 65 mmHg. He was administered intravenous piperacillin-tazobactam, metronidazole and voriconazole. After rapid sequence induction with etomidate 12 mg, midazolam 2 mg, fentanyl 150 μg and succinylcholine 100 mg, trachea was intubated with a left-sided (37 French) double-lumen tube (DLT). Anaesthesia was maintained with sevoflurane 1.5% and vecuronium. During one-lung ventilation, we encountered difficulty in maintaining oxygen saturation (despite increasing FiO2 to 1.0 and positive end-expiratory pressure to 8 cmH2O) and resumed two lung ventilation thrice. The serial ABGs, central venous oxygen saturation (CvO2) and lactate levels were monitored [Table 1]. Thoracotomy revealed a 3 cm longitudinal perforation in the distal oesophagus. The perforation was sutured. A nasogastric tube was inserted, and the pleural cavity was lavaged with saline and the chest wall was closed in layers. A feeding jejunostomy was performed. Fluid management was guided by CVP (target value-10 mmHg) and urine output (0.5 ml/kg/h). After surgery, an epidural catheter was inserted in the T9-T10 interspace, and the DLT was replaced with a single-lumen endotracheal tube.
Table 1
Haemodynamics and arterial blood gases before, during and after surgical repair
Haemodynamics and arterial blood gases before, during and after surgical repairSerial lactate levels reduced and CvO2 levels improved over the next 24 h. Inotropes were weaned off on the 2nd post-operative day (POD). Extubation and removal of epidural catheter were carried out on 1st and 3rd POD, respectively. On the 10th POD, a gastrografin swallow was performed which showed free-flowing contrast from oesophagus into the stomach, without any leakage. He was then started on oral feeds and discharged home on the 19th POD.Anaesthetic management entails timely institution of aggressive resuscitative measures, guided by invasive monitoring. Induction should be smooth, avoiding increases in abdominal pressure, which may exacerbate leakage of gastroesophageal contents and minimising aspiration risk by rapid sequence induction.[34] The occurrence of arrhythmias is a possibility when the surgeon is in proximity to the pericardium. Lung isolation (for adequate surgical exposure) and intra-operative use of protective ventilatory strategies can prevent adverse events in this otherwise life-threatening situation.
Figure 1