Page 6 - CASA Bulletin of Anesthesiology 2022; 9(3)-1 (1)

CASA Bulletin of Anesthesiology

intermittently, completely or selectively based on surgical requirement. Anesthesia providers will
maintain intraoperative low central venous pressure (CVP) to decrease hepatic veins backflow
bleeding and hepatic congestion during parenchymal transection. CVP could be achieved
between 0 ~ 5mmHg by fluid restriction, pharmacologic intervention and patient positioning 6, 10-
11 . However, the risk of VAE increased as the CVP decreased, and it has been a great challenge
for anesthesia providers to balance the hemodynamic and metabolic stabilities intraoperatively
with low CVP.

The true incidence of air embolism associated with liver surgery is unknown and may be
underdiagnosed. As there is significant morbidity and mortality associated with acute VAE, it is
paramount for all anesthesia providers to have an awareness of the planned surgery and
associated risk factors, the patient’s clinical presentation and to recognize and promptly manage
the pathological consequences 2, 12 .

Case report

History

A 36-year-old female was referred to the hospital with a diagnosis of metastatic pancreatic
neuroendocrine tumor to liver. She first experienced shortness of breath, fever, chills, dry cough,
fatigue and workup with CT showed numerous liver masses with the largest, 17X13 cm, in the
right lobe. These masses compressed the intrahepatic IVC and middle hepatic vein, and the right
hepatic vein was severely compressed and not well visualized. There was a 3.2X4.2cm of the
pancreatic tail. A biopsy of a liver lesion was consistent with metastatic neuroendocrine tumor,
and radioactive Dotatate scan showing multiple large centrally necrotic liver mass with
hepatosplenomegaly, focal uptake in pancreatic tail and multiple retroperitoneal and mediastinal
lymph nodes.

She started on capecitabine and temozolomide (CAPTEM) chemotherapy and completed 5
cycles. She also started sandostatin 20 mg monthly injections. She has no known allergies to
medications. She has been feeling well and resumed an active exercise regimen prior to surgery.
Her past medical history was only remarkable for febrile petit mal seizures in childhood. Anti-
epileptics had been initiated and she remained seizure-free since childhood, Anti-epileptics were
discontinued when she was 10 year old.
Preoperative preparation

On admission, the patient's physical examination was unremarkable. All preoperative blood
tests were within normal limits except total bilirubin 3-4.6 mg/dL. EKG, CXR, and her
preoperative vital signs were normal. In the light of tumor location, size and compression to
intrahepatic IVC and hepatic vein, and possible IVC clamps during the surgery, venovenous
bypass (VVB) and cell saver were requested for this procedure.

Operative Course

The patient was scheduled for an exploratory laparotomy, liver tumor resection, distal
pancreatectomy and splenectomy. A thoracic epidural catheter was placed at the T9-10
interspace and 1% lidocaine injected to achieve an appropriate sensory block under routine
monitoring. General anesthesia was induced and the patient intubated using propofol, fentanyl
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