Anesthetic management for surgical removal of renal carcinoma with caval or atrial tumor thrombus using deep hypothermic circulatory arrest

Abstract

Twenty cases of renal carcinoma with tumor thrombus extending into the vena cava or atrium, in which cardiopulmonary bypass (CPB) and deep hypothermic circulatory arrest (DHCA) were used, are reviewed. Arterial, central venous (n = 9), or pulmonary artery catheters (n = 11), ECG, and rectal or bladder and pharyngeal temperatures were used for monitoring. The anesthetic was a high-dose narcotic supplemented with a nondepolarizing relaxant and a volatile agent. The surgery consisted of mobilization of the kidney followed by CPB via atrial and aortic cannulae, cooling via CPB, exsanguination, and removal of thrombus during DHCA. Duration of cooling was 21 +/- 7 minutes to a pharyngeal temperature of 15.8 degrees +/- 2.6 degrees C with alpha-stat pH management; DHCA lasted 26 +/- 10 minutes, and rewarming was continued to a mean pelvic temperature of 36.2 degrees C. Duration of surgery was 8.1 +/- 1.6 hours. The mean initial hematocrit was 33.5%, mean lowest Hct during CPB was 16.9%, and mean Hct at the end of surgery was 30%. Intraoperatively, 9.0 +/- 6.4 units of blood were used, and most patients received component therapy. Average crystalloid use was 7 L, and albumin or hetastarch (1.3 +/- 0.9 L) was used in 13 patients. One patient with severe cardiac disease could not be weaned from CPB. In the 19 operative survivors, there were no neurological deficits. There was one late death from pulmonary complications. The use of thiopental (n = 13), dexamethasone (n = 11), or mannitol (n = 19) was not clearly related to outcome. Hypothermia, hemodilution, alpha-stat pH management, and normoglycemia are believed to be important aspects of perioperative care.(ABSTRACT TRUNCATED AT 250 WORDS)