Users Online: 1275 Home Print this page Email this page Small font sizeDefault font sizeIncrease font size  
Home | About us | Editorial board | Search | Ahead of print | Current issue | Archives | Submit article | Instructions | Subscribe | Contacts | Login 


RSACP wishes to inform that it shall be discontinuing the dispatch of print copy of JOACP to it's Life members. The print copy of JOACP will be posted only to those life members who send us a written confirmation for continuation of print copy.
Kindly email your affirmation for print copies to dranjugrewal@gmail.com preferably by 30th June 2019.

 

 
Table of Contents
LETTER TO EDITOR
Year : 2019  |  Volume : 35  |  Issue : 2  |  Page : 271-273

Pulmonary arterio venous malformations - What the anesthesiologist must know


Department of Anaesthesiology, Seth GS Medical College and KEM Hospital, Mumbai, Maharashtra, India

Date of Web Publication25-Jun-2019

Correspondence Address:
Supriya Dsouza
Department of Anaesthesiology, Seth GS Medical College and KEM Hospital, Mumbai, Maharashtra
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/joacp.JOACP_181_18

Rights and Permissions

How to cite this article:
Lakshmi B K, Dsouza S, Kulkarni A, Kamble J, Garasia M. Pulmonary arterio venous malformations - What the anesthesiologist must know. J Anaesthesiol Clin Pharmacol 2019;35:271-3

How to cite this URL:
Lakshmi B K, Dsouza S, Kulkarni A, Kamble J, Garasia M. Pulmonary arterio venous malformations - What the anesthesiologist must know. J Anaesthesiol Clin Pharmacol [serial online] 2019 [cited 2019 Sep 19];35:271-3. Available from: http://www.joacp.org/text.asp?2019/35/2/271/261281



Madam,

A 11-year-old male child diagnosed to have pulmonary arteriovenous malformations (PAVM) 6 years back, treated with embolization and coiling twice in the past presented with exertional dyspnea and cyanosis since 2 months. Chest x-ray showed increased bronchovascular markings and coils [Figure 1]. Computed tomography pulmonary angiography revealed bilateral arteriovenous malformations in the right middle and lower lobes, and the left upper and lower lobes. 2D Echo and USG abdomen were unremarkable. Hemoglobin was 19.3 g%, PCV was 62.5% which settled to 16.4 g%, and 54.9% after two exchange transfusions. ABG in sitting position on room air revealed a pO2 of 25.2 mmHg and SaO2 of 40.4% and a pO2 of 35 mmHg and SaO2 of 66% in the supine position. pCO2 was normal in both ABGs. The treatment plan was repeat embolization under general anesthesia.
Figure 1: Digital Subtraction Angiography image showing coils in the pulmonary vasculature

Click here to view


After adequate hydration and antibiotic prophylaxis, the child was preoxygenated with 100% oxygen and anesthesia was induced with Inj. Midazolam 0.03 mg/kg iv, Inj. Fentanyl 2 μg/kg iv, Inj. Propofol 2 mg/kg iv, and Inj. Vecuronium 0.1 mg/kg iv, intubated with 6-mm cuffed endotracheal tube and anesthesia was maintained with 50%–50% oxygen–air mixture and propofol infusion at 50–100 μg/kg/min. Extreme care was taken to keep the intravenous line free of air bubbles. The intraoperative oxygen saturation varied between 56% and 62% and improved to 77% after embolization. Neuromuscular blockade was reversed and trachea extubated uneventfully. Immediate post-operative ABG taken in supine position showed a pO2 of 36 mmHg and a SaO2 of 70%. SPO2 was 65% in sitting position and 75% in supine position. In post-operative period, there was a reduction of Hb (11.9 g%) and PCV (39.1%).

PAVMs are abnormal pulmonary arteries and pulmonary veins communicating directly without interposition of a capillary bed. About 80%-90% of patients with PAVMs eventually may present with hereditary hemorrhagic telangiectasia (HHT), whereas others are sporadic.[1] Due to the PAVMs typically being located in the lower lobes, postural changes in the degree of shunt in the supine position characteristically show an improvement in oxygenation (as measured by pulse oximetry or arterial gas sampling) over those in the sitting position.[2] Risks include rupture presenting with massive hemoptysis and/or hemothorax, significant right to left shunt resulting in hypoxemia, heart failure, and the potential passage of emboli across the shunt into the systemic circulation causing complications, such as stroke and cerebral or systemic abscesses.[3]

PAVM poses quite a challenge to the anesthesiologist. Adequate hydration and exchange transfusion is needed if overt polycythemia is present as in our case, to maintain fluidity of blood and prevent sludging. Preoperative optimization of fluid status also helps maintain blood pressure.[4] Great care should be exercised to avoid injecting even a minuscule air bubble with intravenous medications. Drug syringes, stopcocks, and all other air-trapping components of intravenous tubings should be cleared before use as capillary filter is lost in these patients. Antibiotic prophylaxis is essential as paradoxical shunting of emboli from the venous to the arterial circulation occurs leading to unfiltered blood returning to the heart causing septic embolism especially brain abscesses.[5] Positive pressure ventilation may exacerbate shunting in PAVM and worsen hypoxemia; hence, spontaneous ventilation or breathing must be maintained or restored as soon as possible. PAVM causes a right to left shunt and may result in hypoxemia or mimic symptoms of airway obstruction. Oxygenated arterial blood bypasses the microcirculation where gas exchange occurs resulting in hypoxemia.[6] Rise in blood pressure can be detrimental, so maintaining it within 20% of baseline is important especially during induction and emergence. Blunting of the pressor response and intraoperative propofol infusion can help maintain the blood pressure. However, since patients with AV malformations have a right to left shunt and decrease in systemic vascular resistance (SVR), anesthesia-induced drop in SVR is a concern. An unpredictable response to induced hypotension is seen due to the absence of tone in the AV malformation and so is the response to vasopressors. Intraoperatively rise in airway pressures is to be avoided to prevent rupture of AV malformations and increase in shunt and hypoxia; hence, the use of lower tidal volumes is prudent.[7] Total intravenous anesthesia seems appropriate to avoid the inhibition of hypoxic pulmonary vasoconstriction and worsening of shunting by inhalational anesthetics.[8]

Reassurance that the anesthesia provider is familiar with this rare condition and anesthesia considerations to prevent adverse outcomes will engage the trust and confidence of the patient in his/her anesthesiologist and help ease anxieties. A basic knowledge of the challenges presented by this syndrome is the first step in providing a safe and effective anesthetic technique.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Burke CM, Safai C, Nelson DP, Raffin TA. Pulmonary arteriovenous malformations: A critical update. Am Rev Respir Dis 1986;134:334-9.  Back to cited text no. 1
    
2.
Chao HS, Chern MS, Chen YC, Chang SC. Recurrence of pulmonary arteriovenous malformations in a female with hereditary hemorrhagic telangiectasia. Am J Med Sci 2004;327:294-8.  Back to cited text no. 2
    
3.
Ference BA, Shannon TM, White RI Jr, Zawin M, Burdge CM. Life threatening pulmonary hemorrhage with pulmonary arteriovenous malformations and hereditary hemorrhagic telangiectasia. Chest 1994;106:1387-90.  Back to cited text no. 3
    
4.
Bhalerao PM, Pandit SC, Swati V, Jadhawar ST. Anaesthetic management of a patient with Osler-Weber-Rendu's syndrome posted for Young's procedure. Indian J Anaesth 2014;58:493-4.  Back to cited text no. 4
[PUBMED]  [Full text]  
5.
Shovlin CL, Jackson JE, Bamford KB, Jenkins IH, Benjamin AR, Ramadan H, et al. Primary determinants of ischaemic stroke/brain abscess risks are independent of severity of pulmonary arteriovenous malformations in hereditary haemorrhagic telangiectasia. Thorax 2008;63:259-66.  Back to cited text no. 5
    
6.
Radu C, Reich DL, Tamman R. Anaesthetic considerations in a cardiac surgical patient with Osler-Weber-Rendu disease. J Cardiothorac Vasc Anesth 1992;6:461-4.  Back to cited text no. 6
    
7.
Peiffer KM. Anesthetic considerations for the patient with hereditary hemorrhagic telangiectasia. AANA J 2009;77:115-8.  Back to cited text no. 7
    
8.
Kim JC, Lee KC, Choi JL, Lee HD, Kwak HJ. Anaesthetic management of a patient with pulmonary arteriovenous malformation under total intravenous anaesthesia: A case report. Korean J Anesthesiol 2009;56:713-6.  Back to cited text no. 8
    


    Figures

  [Figure 1]



 

Top
 
  Search
 
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
    Access Statistics
    Email Alert *
    Add to My List *
* Registration required (free)  

 
  In this article
   References
   Article Figures

 Article Access Statistics
    Viewed179    
    Printed6    
    Emailed0    
    PDF Downloaded34    
    Comments [Add]    

Recommend this journal