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BJA Advance Access published online on February 20, 2004
British Journal of Anaesthesia, doi:10.1093/bja/aeh104
© 2004 by The Board of Management and Trustees of the British Journal of Anaesthesia
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Accepted August 9, 2003

Case Reports

A fine balance--one-lung ventilation in a patient with Eisenmenger syndrome

A. R. Heller 1*, R. Litz 1, T. Koch 1

1 Department of Anaesthesiology and Intensive Care Medicine, University Hospital Carl Gustav Carus, Harvard Medical International Associated Institution, Fetscherstrasse 74, D-01307 Dresden, Germany

* To whom correspondence should be addressed. E-mail: axel.heller{at}mailbox.tu-dresden.de.


  Abstract

A 38-yr-old woman with an atrial septum defect and Eisenmenger syndrome was scheduled for a lung biopsy via thoracoscopy during one-lung ventilation. Fluids were given to increase central venous pressure to 8 mm Hg, an epidural catheter was inserted at the sixth thoracic intervertebral space and ropivacaine 0.3%, 6 ml were given. Careful balance of systemic and pulmonary vascular resistance is crucial in Eisenmenger syndrome, so norepinephrine (0.14 mg kg-1 min-1) was infused before general anaesthesia was started with fentanyl 4 mg kg-1, ketamine 2 mg kg-1, pancuronium 1 mg and succinylcholine 2 mg kg-1. Anaesthesia was maintained with propofol 4-8 mg kg-1 h-1. To control pulmonary artery pressure, ventilation was performed with oxygen 100% and nitric oxide 20 ppm. Surgery and anaesthesia course were uneventful and the patient was extubated. However, pleural haemorrhage required treatment with blood components, re-intubation on the second postoperative day and removal of the haematoma by mini-thoracotomy. A step-by-step approach using a balanced combination of regional and general anaesthesia, controlled fluid administration, norepinephrine and inhaled nitric oxide preserved a stable circulation even during one-lung ventilation. The diagnostic value of lung biopsy must be weighed against the possibility of life-threatening haemorrhage.

Keywords: Keywords: anaesthetic techniques, epidural; complications, atrial heart septum defect; complications, pulmonary hypertension; lung, thoracoscopy


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