Case presentation
A 79-year-old man (height, 169 cm; weight 79 kg) was scheduled for total
cystectomy and ileal conduit diversion for bladder cancer. The patient
had a history of acute myeloid leukemia and achieved remission by
chemotherapy 9 years earlier. He was diagnosed with a thoracic aortic
aneurysm and myocardial infarction, and underwent total arch replacement
and coronary artery bypass grafting 3 years earlier.
His blood pressure, heart rate,
and peripheral blood oxygen saturation (SpO2) while
breathing room air were 110/70 mmHg, 90 bpm, and 98%, respectively. On
chest X-ray, the cardiothoracic ratio (CTR) was 58% with normal lung
fields (Figure 1a). Transthoracic echocardiography showed normal cardiac
function with left ventricular
ejection fraction (LVEF) of 50%. The complete blood cell count showed
anemia and thrombocytopenia (RBC 2.83 x 106/μL,
hemoglobin 8.9 g/dL, hematocrit 26.7%, and platelets 1.0 x
105/μL). He was scheduled to receive intraoperative
platelet transfusion.
For anesthesia induction, he received intravenous midazolam 7 mg and
remifentanil 0.2 μg/kg/min, and endotracheal intubation was carried out
with rocuronium 50 mg as a muscle relaxant. Anesthesia status was
maintained using 4% desflurane and remifentanil 0.1 - 0.2 μg/kg/min.
When his blood pressure dropped, ephedrine and/or phenylephrine was
administered as needed. Standard intraoperative monitoring and invasive
blood pressure measurement were carried out. Platelet transfusion was
initiated at the beginning of the surgery, and the blood oxygenation
level of the patient gradually decreased 40 minutes after the
transfusion, with SpO2 of 92-95% at fraction of
inspired oxygen (FiO2) of 0.5, and a large amount of
foamy sputum was suctioned from the endotracheal tube. The patient
became hypotensive, and noradrenaline administration was initiated. The
patient was transfused with packed red blood cells (560 mL), platelets
(400 mL), and 5% albumin (1000 mL). The total amount of fluid infusion
was 5100 mL; total blood loss was 1552 mL, and total urine volume was
100 mL. Total operation time was 3 h 59 min, and total anesthesia time
was 5 h 18 min. The postoperative chest X-ray showed bilateral pulmonary
edema (Figure 1b). The patient showed a poor oxygenation level with a
PaO2/FiO2 (P/F) of 70.1 and was
transferred to the intensive care unit (ICU) under sedation and
mechanical ventilation. After transfer to the ICU, bleeding from the
drainage tube continued, and anemia progressed. Therefore, he was
scheduled for emergency hemostasis in the operating room 1 hour after
admission to the ICU.
Anesthesia was maintained using desflurane and remifentanil, and
continuous administration of sivelestat was added. Steroid was also
administered to correct increased vascular permeability. During the
operation, foamy secretions were continuously produced from the
endotracheal tube and removed using a bronchofiberscope and suction
tube. A recruitment maneuver was also manually carried out whenever
necessary. TRALI was suspected from the clinical course. After surgical
hemostasis, blood gas analysis at FiO2 1.0 showed pH
7.06, PaCO2 96.1 mmHg, PaO2 67.9 mmHg,
and HCO3- 26.1 mmol/L, indicating severe hypoxemia and
hypercapnia. VV-ECMO support was then
started.
His chest X-ray at the beginning of VV-ECMO support showed infiltration
in the entire lung field (Figure 1c). He received continuous treatment
with steroid and sivelestat. After VV-ECMO support was started,
hypoxemia and hypercapnia improved markedly. Under VV-ECMO support,
mechanical ventilation with driving pressure at 10
cmH2O, PEEP at 10 cmH2O, and
FiO2 at 0.4 was provided. His lung condition improved
gradually, and foamy secretions decreased from postoperative day (POD)
2. The chest X-ray image improved markedly. His further clinical course
was good, and he was weaned off VV-ECMO on POD6 and mechanical
ventilation on POD7. He was then discharged from the ICU. Antibody
testing of donor serum was performed for TRALI diagnosis, and the
anti-HLA Class II antibody was positive, and a positive cross reaction
to the patient’s white blood cells was confirmed.