Endobronchial hemorrhage after intubation with double-lumen endotracheal tube in a patient with idiopathic thrombocytopenic purpura for minimally invasive cardiac surgery: a case report
A 62-year-old man (169 cm in height and 69 kg in weight) was admitted to hospital with dizziness and paresthesia of both hands. He was diagnosed with cerebral infarction, and while doing additional examination, cerebral infarction was assumed to be due to infective endocarditis. Transthoracic echocardiography showed large and hypermobile vegetations on anterior mitral leaflet. He was scheduled to have mitral valve replacement using MICS due to tremendous risk of systemic embolism.\nTwo months back, he was admitted to the Department of Neurosurgery in our hospital because of subarachnoid hemorrhage in left central sulcus and precentral sulcus, and blood spots on the lower limbs and thrombocytopenia (33,000 /mm3) were incidentally detected. Although in a bone marrow aspiration, pathologic finding was not observed and the platelet associated immunoglobulins was negative, ITP was clinically diagnosed. However, steroid therapy was not started immediately and his platelet count was examined as needed.\nHis platelet count was 40,000 /mm3 the day before surgery. Because MICS needed the use of heparin prior to cardiopulmonary bypass (CPB), we decided to transfuse platelets after surgery. For premedication, 0.2 mg of glycopyrrolate was injected intramuscularly 30 minutes before the surgery. Vital signs at the time of arrival at the operation room were blood pressure at 125/75 mmHg, heart rate at 98 beats/min, and oxygen saturation (SpO2) as 99%.\nFor the induction of anesthesia, while 0.1 µg/kg/min of remifentanil was infused for three minutes, 10 mg of etomidate and 10 mg of cisatracurium were also injected. Then a left-sided 35-french DLT was intubated with a stylet. The stylet was removed immediately after the tip of DLT passed through the vocal cords. When the tube was inserted at a depth of 29 cm to lips, resistance was felt. Tracheal cuff and the bronchial cuff were inflated with 6 ml and 2 ml of air, respectively. After making a judgment that the location of tube was appropriate by using bronchoscope, the bronchial cuff was deflated in order to prevent bronchial injury from postural changes, and there was no bleeding. Anesthesia was maintained with sevoflurane 1.5 vol%, oxygen 1.0 L/min, medical air 1.5 L/min and remifentanil 0.12 µg/kg/min were continuously infused intravenously. The patient underwent DLT change when we detected leakage of endotracheal balloon. After the exchange of DLT using tube exchange catheter, we confirmed the location of the DLT by using bronchoscope, and there was no bleeding. Insertion of superior vena cava (SVC) drainage catheter and central venous pressure catheter were performed via right internal jugular vein. Heparin 2,100 IU was administered to prevent clot formation of SVC drainage catheter. There was no sign of bleeding during those procedures. At the end of the procedure, we detected bleeding from the left side of DLT. The appearance of the bleeding was blood-tinged or frothy pink like pulmonary edema. The bleeding was sucked via suction catheter and the amount of the bleeding was about 150-200 ml. Due to the bleeding via the left side of DLT, we carried out lung separation immediately and decided to check the location of the bleeding with a fiberoptic bronchoscope. The carinal region and the left and the right bronchus were examined with a fiberoptic bronchoscope, but the focus of the bleeding in the traveling direction from the left mainstem bronchus was not detected. Because fiberoptic bronchoscopic view had poor visibility due to blood, we could not detect the focus of the bleeding and active bleeding from bronchus. Also, there was no bleeding via right side of DLT. Because we could not find the evidence of tracheobronchial laceration or rupture and the patient did not have any subcutaneous emphysema, and pneumomediastium, we excluded the possibility of mechanical injury of airway.\nBlood loss was estimated to be 150-200 ml over 30 min. Therefore, we suspected bronchial arterial injury; MICS was immediately stopped and bronchial artery embolization was scheduled in the angiographic room. Vital signs at that time, were blood pressure (BP) at 105/50 mmHg, heart rate (HR) at 115 beats/min, and SpO2 89%. During the transportation of the patient to the angiographic room, gradual decrease in the bleeding was noted, and the patient's vital signs in the angiographic room were stable (BP at 110-120/50-80 mmHg, HR 100 beats/min, and SpO2 99-100%). Angiography of the bronchial artery was performed, but focus of the bleeding was not found (). With reference to the risk of re-bleeding from the injured bronchial artery and the possibility of uncontrolled bleeding in patient with ITP, we decided to embolize the contributing bronchial arteries. After finishing the embolization of bilateral bronchial arteries, the chest X-ray was checked, and total atelectasis of left lung was observed (). There was no evidence of active bleeding, but blood clot was detected and removed using bronchoscope. After the removal of blood clot, an improvement in lung collapse was noted.\nThe patient was scheduled for MICS 6 days later. Due to lowered platelet count (54,000 /mm3), a high-dose IVIG therapy (35 g/day, 0.5 g/kg) for 2 days was started. Platelet count was increased to 87,000 /mm3 after 6 days. We intubated with single lumen endotracheal tube and lung isolation was achieved with intermittent total lung deflation. The surgery was done safely, and the outcome was favorable for the patient without any postsurgical decrease in platelet count or bleeding. He was extubated on the postoperative day (POD) 2, and transferred from the intensive care unit to the ward on POD 5. The patient left the hospital after making a full recovery on POD 28.