Unilateral Cerebral Oxygen Desaturation during Emergent Repair of a DeBakey Type 1 Aortic Dissection: Potential Aversion of a Major Catastrophe

Abstract

MASSIVE pulmonary embolism (PE), although an uncommon complication in liver transplant surgery is associated with a high mortality rate.Five of nine patients reported to have massive PE in the past 12 yr died from this complication. 1,2 We report a case of PE that occurred in the same patient during two consecutive liver transplant procedures in association with the use of an antifibrinolytic and hepatitis B immune globulin (HBIG). Case ReportA 52-yr-old man was admitted for orthotopic liver transplantation because of end-stage liver disease secondary to hepatitis B and C and recurrent hepatocellular carcinoma.Two years before admission, he had intractable ascites and severe portal hypertension for which a transjugular intrahepatic portosystemic shunt procedure was performed.Previous operations for repair of inguinal and umbilical hernias as well as a splenectomy 7 yr before the current admission for thrombocytopenia were without complications.Physical examination revealed a well-nourished patient with no abnormalities of the cardiovascular or respiratory systems.An echocardiogram showed normal cardiac function with an ejection fraction between 55 and 60% and no discrete vegetations, mural thrombi, or intracardiac masses.Laboratory results included prothrombin time of 17.6 s, international normalized ratio (INR) of 1.7, partial thromboplastin time of 31.1 s, fibrinogen of 128 mg/dl, and platelet count of 128 ϫ 10 9 /l.Anesthesia was induced in a rapid-sequence manner with thiopental and succinylcholine and was maintained with isoflurane and cisatracurium.A loading dose of 5 g ⑀-aminocaproic acid followed by an infusion of 1 g/h was started as per our usual practice.A CaCl 2 infusion at 1 g/h was also started.A right radial arterial catheter was placed, and two 9-French ports (Arrow, Reading, PA) were inserted in the right internal jugular vein through which a 7.5-French pulmonary artery (PA) catheter (Baxter, Oakland, CA) was inserted in one without difficulty.Initial blood pressure was 140/70 mmHg; heart rate was 75 beats/min; pulmonary arterial pressure was 37/25 mmHg; cardiac output was 6.4 l/min, and central venous pressure was 16 mmHg.Venovenous bypass with a centrifugal pump (Biomedicus; Medtronic, Eden Prairie, MN) and nonheparinized tubing was started at a flow of 1.8 -2