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A Case of Life-Threatening Hypertensive Crisis during Hepatic Radiofrequency Ablation

A Case of Life-Threatening Hypertensive Crisis during Hepatic Radiofrequency Ablation. Raza Zaidi, MD Satya Krishna Ramachandran, MD Department of Anesthesiology University of Michigan Hospitals. Case Background. 55 year-old male  Hepatitis C and hepatocellular carcinoma

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A Case of Life-Threatening Hypertensive Crisis during Hepatic Radiofrequency Ablation

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  1. A Case of Life-Threatening Hypertensive Crisis during Hepatic Radiofrequency Ablation Raza Zaidi, MD Satya Krishna Ramachandran, MD Department of Anesthesiology University of Michigan Hospitals

  2. Case Background • 55 year-old male  • Hepatitis C and hepatocellular carcinoma • Laparoscopic hand-assisted RFA of liver mass

  3. Patient History Anesthetic Hx: DL: Grade 2B view Social Hx: Remote hx of IVDA Family Hx: Diabetes, HTN • PSH • Lap liver resection • Tonsillectomy • PMH • HCV cirrhosis/HCC • DM II • Nephrolithiasis • HTN • HL • GERD (poorly controlled) • Morbid obesity • Chronic back pain

  4. Medications • Glyburide • Glucophage • Insulin glargine • Alprazolam • Omeprazole • ASA • Norco • Allergies • Amlodipine – headaches • NSAIDs – ulcers • Simvastatin – diarrhea

  5. Pre-op Studies 14.5 • EKG: NSR • Dobutamine Stress Echo: EF 65%. No inducible ischemia. Grade 1 LV dysfunction Lab Values: 136 14 105 90 4.7 108 4.8 26 0.7 43.7 AST 81 ALT 96 INR 1.0

  6. MRI Lesion

  7. Hepatic Segmental Anatomy Traditional Surgical Viewpoint of Liver Anatomy and Definition of the Couinaud Segments  3-D tutorials of the Division of Physiologic Imaging, Dept. of Radiology, Univ. of Iowa

  8. Hepatic Radiofrequency Thermal Ablation Di Benedetto et al. (2012) Journal of Laparoendoscopic & Advanced Surgical Techniques

  9. Hepatic RFA Advantages • Minimal invasiveness • Treatment modality for unresectable lesions • Reduced cost/hospital stay1 • Potential for repeated treatment for local recurrence 1L. Solbiati et al. European Journal of Ultrasound 13 (2011) 149–158

  10. Physical Exam • Afebrile • BP 139/77 • HR 94 BPM • O2 sat 95% on RA • 5’6” 120 kg, BMI 42.7 • Airway Exam: Mallampati III w/ thick, obese neck

  11. Anesthetic Plan • GETA, RSI • Arterial line for hemodynamic monitoring • 2nd IV after induction • T & S

  12. Induction • Midazolam, fentanyl, propofol, succinylcholine • Atraumatic endotracheal intubation on 1st attempt • Arterial line and16g IV placed Arterial line placed

  13. Intraoperative Course Surgical incision RFA started

  14. Intraoperative Course BP 300/135 RFA started

  15. Differential Diagnosis • Mechanical/Systems Error • Inadequate depth of anesthesia • Surgical factors • Pharmacologic • Physiologic/Pathologic

  16. Next Steps… • Communication • Increased inhalation agent • Propofol/fentanyl boluses • RFA aborted • Labetalol given

  17. Intraoperative Course RFA aborted

  18. Intraoperative Course RFA restarted

  19. Intraoperative Course RFA restarted RFA aborted

  20. Intraoperative Course

  21. …Try, Try Again?

  22. American Journal of Roentgenology (2003)

  23. Imaging AJR:181, August 2003

  24. Imaging AJR:181, August 2003

  25. Patient’s MRI Lesion Adrenal Gland

  26. Intraoperative Course RFA restarted

  27. Hypertensive Crisis • Hypertensive emergency - severe elevations in BP [>180/110 mm Hg] complicated by evidence of impending or progressive target organ dysfunction* • Hypertensive urgency - severe elevations in BP without progressive target organ dysfunction. *Sixth Report of the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure (JNC6) (Chobanian et al 2003a; JNC 1997)

  28. Pathophysiology of Hypertensive Crisis

  29. Complications of Hypertensive Crisis • Cardiovascular • Neurologic • Renal

  30. Pharmacological Management of Acute Intraoperative Hypertensive Crisis • Peripheral vasodilators • β-adrenergic blockade

  31. Overview of intravenous drugs for the treatment of intraoperative hypertensive emergencies Van den Born, et al. Dutch Guideline for the Management of Hypertensive Crisis- 2010 revision. The Netherlands Journal of Medicine

  32. Postoperative Course • Extubated awake after reassuring neuro exam • Serial neuro exams • Uncomplicated postop course Discharged home on POD #1

  33. RFA Complications • Thermal/Mechanical injury to surrounding structures • Bowel perforation • Cholecystitis • Bile duct stricture • Portal vein thrombosis • Adrenal gland injury  HTN crisis

  34. Recommendations • Consider arterial line for tumors near the adrenal gland • Potential of hypertensive crisis - a contraindication for hepatic radiofrequency ablation?

  35. Lessons Learned • Understand the surgical procedure • Review the imaging • Importance of communication/information technology

  36. Patient Follow-up • “Patient appears to have tolerated therapeutic intervention well with no residual cancer at the site of previous intervention. Unfortunately, patient has evidence of a new lesion concerning for recurrence. We will plan to review his most recent imaging at our upcoming Liver Tumor Board to make additional recommendation regarding his care and potential intervention in the future…”

  37. Thank You

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