Pre‐emptive veno‐arterial ECMO in a giant compressive goiter‐related difficult airway: A case report

A 64-year-old patient required emergency surgery with high risk of intubation failure, without any possibility to perform neither a direct transtracheal access nor VV-ECMO canulation. The patient was managed thanks to a VA-ECMO despite the absence of cardiac function impairment. This report describes perioperative challenges and management of this unconventional case with favorable outcome. Severe tracheal stenoses are rare and challenging for anesthesia teams1 due difficult airway management. We present the didactic anesthetic management of a severe undiagnosed thyroid mass requiring an emergency surgery for dyspnea. A 64-year-old woman presented in our tertiary university hospital emergency department for dyspnea with a huge cervical mass (Figure 1, about 21 × 16 × 13 cm). She reported a goiter growing quickly since about 2 weeks, now responsible of dysphagia and dyspnea. A CT scan shown a goiter with retrosternal extension and compression of trachea and esophagus (Figure 2, narrowest part: 4 mm). The patient was hospitalized for a fast surgery. If difficult airway management is well described, current algorithms were inadequate to this clinical situation due to the high risk of intubation failure without any possibility to perform a direct transtracheal access by cricothyrotomy. Veno-venous extracorporeal membrane oxygenation (V-V ECMO) was initially purposed, but the jugular access was considered as unsuitable due to the compression exerted by the mass on the internal jugular veins. Therefore, we used a femoro-femoral veno-arterial ECMO (V-A ECMO). However, V-A ECMO used on a patient without any cardiac dysfunction involved the risk of the competition between the pump and the patient's heart. Thus, necessary drugs for hemodynamic management and modulation of cardiac output were prepared (norepinephrine, epinephrine, esmolol). The additional equipment to add an axillary cannula in case of refractory Arlequin syndrome was available in the operating room. Sedation was initiated carefully with a continuous infusion of Propofol using target plasma concentration (TPC). After an intravenous bolus of 2500 UI of unfractionated heparin, percutaneous cannulations were performed on the right femoral vessels. Then, the V-A ECMO was started to 2.2 L/min/m2 (Maquet® Bioline coated circuit, sweep gas flow: 1.5 L/min, FiO2 = 40%). Continuous infusion of unfractionated heparin was delivered at 500 UI/h and adapted to reach an ACT range from 160 to 180 s. Pulse oximetry was continually measured on the right hand. Cerebral NIRS was used to compare oxygenation of the two brain hemispheres. Cardiac bypass tolerance was regularly evaluated by transthoracic echocardiography. After stabilization, propofol target was increased gradually and a continue infusion of remifentanil was initiated to manage airway (TPC for both). No hypoxemia occurred during the procedure, despite several losses of spontaneous breathing. After reaching an appropriated anesthesia, we proceed to a fibroscopic orotracheal intubation of a Portex® 6.0. After mass resection and decompression of the trachea, we changed the breathing tube for an Portex® 7.0 by a direct laryngoscopy, while on the V-A ECMO. We weaned the V-A ECMO without any difficulty (on-pump duration: 3.5 h) and antagonized heparin after withdrawing the cannulas (protamine sulfate, 1000 UI). We closed the arterial access using the ProGlide® (Abbott Vascular) preclosing device and transferred the patient to our intensive care unit (ICU). She was quickly extubated and with no dyspnea on the first day after the surgery. The hospital stay was favorable. No dysphonia or dysphagia were observed. Severe tracheal compressions are rare but challenging for anesthetic teams. Several authors have reported perioperative management of subocclusive airways using ECMO,2, 3 in prophylaxis4, 5 or in rescue therapy. Most of them used V-V ECMO3 because of the only risk of oxygenation failure without cardiac dysfunction. To our knowledge, this is the first case reporting perioperative management of compressive thyroid mass with prophylactic V-A ECMO. V-A ECMO was chosen due to compressed and inaccessible jugular venous access, even in the absence of cardiac impairment. This preference over femoro-femoral V-V ECMO was influenced by both the lack of experience in our center and a consideration of the potential hemodynamic failure resulting from the substantial release of thyroid hormones during surgery. The choice of anesthetic drugs was made on short half-life molecules to gradually increase the level of sedation and keep as long as possible spontaneous breathing until adequate airway control. Indeed, unlike in V-V ECMO, challenge was to keep a sufficient transpulmonary oxygenation to avoid a competition between V-A ECMO and normal cardiac function (Harlequin syndrome), due to the fact that blood ejected by fully functional patient's heart and not oxygenated by V-A ECMO is more likely to infuse brachiocephalic artery trunk and thus right arm and right brain hemisphere. This problematic was anticipated by increasing gradually V-A ECMO pump flow under control of regional oxygenation with bilateral NIRS and pulse oximetry on the right hand, all along the on-pump duration. Hemodynamic management drugs, including fast-acting betablockers, allowed to treat quickly a Harlequin syndrome by decreasing native cardiac output and reduce competition between heart and V-A ECMO. The evolution was favorable. We described the perioperative management of a severe undiagnosed thyroid mass requiring an emergency surgery under V-A ECMO for difficult airway control and impossibility to cannulate jugular veins to implant V-V ECMO, with favorable evolution. A. Behouche was involved in writing—original draft, investigation; A. Sebestyen was involved in writing—review & editing; L. Guillet was involved in writing—original draft; H. Durand was involved in writing—review & editing; P. Chaffanjon was involved in writing—review & editing; D. Bedague was involved in writing—original draft, writing—review & editing, investigation, supervision. None. None.