Importance of hemodynamic monitoring during esophagectomy - Case Study

Background

Esophagectomy for cancer involves two- or three-phase procedures, such as abdominal, chest and/or neck incisions, is more invasive than other types of gastrointestinal surgery, and is associated with high risk for postoperative morbidity. Because of this risk, perioperative management of circulatory conditions such as hypovolemic hypotension is especially important to avoid postoperative heart complications, anastomotic leak, and conduit necrosis. The addition of continuous cardiac output monitoring provides advanced hemodynamic data that helps the anesthesia and surgical teams manage the patient throughout this high-risk procedure.

Case Presentation

A 58-year-old male with a history of hypertension, diabetes mellitus, and prostate cancer was admitted for a video-assisted thoracoscopic surgery (VATS) esophagectomy. Case started with patient in extreme reverse Trendelenburg with LR infusion to gravity. IM ephedrine 25 mg was administered for long-acting blood pressure control. Gastric dissection contributed to intravascular volume loss and IV bolus ephedrine 10 mg was started to correct the hypotension.  Patient was re-positioned to supine and a dual-lumen ETTwas placed for the next part of the procedure. The patient had a difficult re-intubation that caused acute hypoxia and a compensatory increase in HR. Patient was re-positioned to left lateral, then the right lung was collapsed to allow access to and resection of the esophagus. After clean margins were confirmed, an end-to-end attachment was made between the residual esophagus and the gastric conduit. Given the high risk of anastomotic leak and conduit necrosis, MAP was carefully monitored, and albumin was given to ensure adequate perfusion because no vasopressors can be given during this time. The pulmonary and vascular challenges present during this type of procedure necessitate vigilance using data provided bythe Argos Cardiac Output Monitor.