Hypothermic circulatory arrest in the management of massive
pulmonary artery hemorrhage following pneumonectomy
Joseph E. Arrowsmith, Andrew C. Cook, Inderpaul Birdi, Andrew J. Ritchie
CaseRepClinPractRev 2002; 3(1):18-20
Background: Massive hemorrhage from the divided pulmonary artery (PA) is a rare and lethal complication of pulmonary resection. In the early postoperative period the cause is invariably inadequate stump ligation, whereas
in the late postoperative period the cause is frequently pleural empyema secondary to bronchopleural fistula. Immediate resuscitation and surgical intervention are required to avert exsanguinations and death.
Case report: We describe a case of life-threatening PA hemorrhage occurring within an hour of pneumonectomy. Initial resuscitation included the rapid infusion of cold blood and colloid directly into the distal aortic arch
– a manoeuvre demonstrated to be neuroprotective in a canine model of exsanguination. At reoperation, repair of the torn pulmonary artery in the face of ongoing hemorrhage proved to be impossible. Adequate surgical access
could only be obtained following the institution of cardiopulmonary bypass (CPB), and ultimately hypothermic circulatory arrest (HCA). Despite prolonged periods of hypotension, massive transfusion of blood products
and over 180 minutes of CPB, the patient rapidly made a complete recovery.
Conclusion: CPB has been used successfully in a range of emergency situations including; major trauma, traumatic PA rupture, pulmonary embolism and hypothermia. To our knowledge there appears to be only one published
report of the use of CPB in the setting of PA hemorrhage during pulmonary resection. We are not aware of any report of the successful use of HCA in this clinical setting. In the setting of massive PA haemorrhage following
pneumonectomy, therefore, the use of CPB with HCA may be used to facilitate surgical repair with excellent clinical outcome.
Keywords: Surgery, thoracic, Postoperative Period, complications, Hemorrhage, Resuscitation, transfusion, Cardiopulmonary Bypass