[The analysis of anesthetic management for renal cell carcinoma with associated inferior vena cava tumor thrombus]

Objective: To explore the key points of anesthetic management for renal cell carcinoma combined with inferior vena cava (IVC) tumor thrombus. Methods: Twenty-seven cases of renal cell carcinoma with inferior vena cava (IVC) tumor thrombus underwent radical nephrectomy and inferior caval venous thrombectomy were reviewed retrospectively during January 2014 to January 2017 in our hospital. Analyzed data includs demographics, classification of tumor, perioperative anesthetic management and monitoring approaches, IVC clamping time , vital signs during cardiopulmonary bypass(CPB), estimated blood loss (EBL), usage of blood products, hospitalization time and ICU time , as well as postoperative outcomes. Results: Clinical staging revealed 5 patients(18.5%) with classⅠtumor thrombus, 11 patients(40.7%) with levelⅡtumor thrombus, 6 patients (22.2%) with level Ⅲ tumor thrombus and 5 patients (18.5%) with level Ⅳ tumor thrombus. All patients had underwent a balanced general anesthesia technique with volatile agents, opioids and muscle relaxants. In addition to standard ASA monitors, all patients had direct arterial pressure and central venous pressure monitoring, and blood warming and infusing system. TEE was utilized in 9(33.3%)patients and in which contains all 5 patients(100%)with level Ⅳ tumor thrombus. Intraoperative TEE guidance resulted in a significant surgical plan modification in 1 patient(11.1%). Compared to patients with class Ⅰ(313 (136, 346) min), classⅡ(302(245, 393)min)and classⅢthrombus tumor(391(272, 505)min), patients with Class Ⅳ had longer operating time (525(481, 647)min, P<0.05). Compared to patients with Class Ⅰ(600(500, 850)ml), Class Ⅱ(1 700(750, 3 000)ml), and Class Ⅲ(1 775(1 500, 3 000)ml), patients with Class Ⅳ had more blood loss(4 000(2 000, 7 000)ml, P<0.05). The clamping time of Class Ⅰ, Class Ⅱ and Class Ⅲ was 8(8, 9)min, 20(13, 26)min and 10(6, 25)min, respectively, and there is no significant difference (P>0.05) within theses group. The probability of pumping norepinephrine of Class Ⅰ(8(8, 9)min), Class Ⅱ(20(13, 26)min), and Class Ⅲ(10(6, 25)min)had no significant difference (χ(2)=5.147, P>0.05). Perioperative mortality was 7.4%. Conclusions: The anesthetic management of Inferior vena cava (IVC) tumor thrombus is rather challenging.The preoperative evaluation with accurate classification of the tumor and the intraoperative intense monitoring of vital signs with appropriate reaction are the key points of anesthetic management for this kind of surgery.

目的: 探讨肾癌合并下腔静脉癌栓手术的麻醉管理要点。 方法: 回顾性分析2014年1月至2017年1月在北京大学第三医院诊断为"肾癌伴下腔静脉癌栓"行"肾癌根治,下腔静脉癌栓取出术"的27例病例资料,包括一般人口学情况、癌栓分级、麻醉技术与监测方法、下腔静脉阻断时间、体外循环情况、术中失血量及血制品输注情况、ICU停留时间、住院时间及转归等。 结果: 27例患者中癌栓分级为Ⅰ级5例、Ⅱ级11例、Ⅲ级6例、Ⅳ级5例。患者全部采用气管插管全身麻醉,均监测有创动脉压和中心静脉压。9例(33.3%)患者进行经食管超声心动图(TEE)监测,其中5例Ⅳ级癌栓患者全部进行TEE监测。在所有行TEE监测的患者中,1例(11.1%)麻醉诱导后经TEE检查改变了癌栓分级从而改变了外科手术方案。Ⅳ级癌栓患者手术时间为525(508,600)min,Ⅰ级、Ⅱ级、Ⅲ级癌栓患者手术时间分别为313(136,346)、302(245,393)、391(272,505)min,差异有统计学意义(χ(2)=10.893,P<0.05)。Ⅳ级癌栓患者术中失血量为4 000(2 000,7 000)ml,明显多于Ⅰ级、Ⅱ级及Ⅲ级癌栓患者的600(500,850)、1 700(750,3 000)、1 775(1 500,3 000)ml,差异有统计学意义(χ(2)=10.344,P<0.05)。Ⅰ级、Ⅱ级、Ⅲ级癌栓患者下腔静脉阻断时间分别为8(8,9)、20(13,26)、10(6,25)min,各级相比差异均无统计学意义(均P>0.05)。术中使用去甲肾上腺素持续泵注的患者比例为Ⅰ级40%、Ⅱ级54.5%、Ⅲ级50%、Ⅳ级100%,差异无统计学意义(χ(2)=5.147,P>0.05)。围手术期死亡率为7.4%。 结论: 肾癌合并下腔静脉癌栓手术的麻醉管理具有挑战性,术前准确评估癌栓分级、术中严密的血流动力学监测及处理是此类手术麻醉管理的要点。.

Zhonghua yi xue za zhi. 2017 Nov 14 [Epub]

H Zeng, X Y Rong, Y Wang, X Y Guo

Department of Anesthesiology, Peking University, Third Hospital, Beijing 100191, China.