Mishra Pragny Adipta, Kausalya Rajini, Jain Rajiv
Department of Anesthesia and Intensive Care Unit, Sultan Qaboos University Hospital, Muscat, Oman.
Middle East J Anaesthesiol. 2011 Feb;21(1):105-10.
To highlight the diagnostic and therapeutic challenges associated with the treatment of a patient with superior vena cava syndrome and a coexisting coagulopathy.
This case report describes a bone marrow transplant patient with graft versus host diseases (GVHD) who was admitted to our intensive care unit with bronchiectasis complicated with nosocomial pneumonia. When he was recovering from pneumonia after prolonged ventilatory support, he developed superior vena cava (SVC) syndrome due to mediastinal lymphadenopathy. The diagnosis was delayed due to associated confounding clinical factors. Because of the rapid deterioration in patient's condition, immediate tissue diagnosis of mediastinal lymph nodes and re-canalization of vena cava by stenting were our priority. He had many other medical problems such as thrombocytopenia, deranged coagulation profile, old cerebral infarction with hemiplegia, seizure disorder and cardiac arrhythmias which complicated the treatment plan. USG guided biopsy followed by stenting of the SVC was done after discussing the risks and benefits with patient's relatives. But, he had bleeding from biopsy site due to deranged coagulation profile. Again for the same reason, he was not given any anticoagulants. Within 24 hours the stent was blocked by clot which was diagnosed by the deteriorating clinical features and repeat CT scan. Then he was given enoxaparin in therapeutic dose and the clot cleared within a day possibly partly due to enoxaparin and partly coagulopathy.
In a bone marrow transplant patient with GVHD, the associated complications can confound the diagnosis of SVC syndrome. Physician has to show high degree of suspicion as it may develop even if patient has coagulopathy due to other factors such mediastinal lymphadenopathy. SVC stent may clot even if the patient has coagulopathy. So, it is advisable to defer the invasive diagnostic procedures such as mediastinal lymph node biopsy till the patient is well stabilized after the stent placement in SVC as it will prevent further use of anticoagulants. Enoxaparin may be helpful in the treatment of stent thrombosis in such patients with multiple complications.
强调治疗上腔静脉综合征合并凝血功能障碍患者时所面临的诊断和治疗挑战。
本病例报告描述了一名患有移植物抗宿主病（GVHD）的骨髓移植患者，因支气管扩张合并医院获得性肺炎入住我们的重症监护病房。在长时间通气支持后肺炎恢复过程中，他因纵隔淋巴结病发展为上腔静脉（SVC）综合征。由于相关的混杂临床因素，诊断被延迟。由于患者病情迅速恶化，对纵隔淋巴结进行即时组织诊断并通过支架置入使腔静脉再通是我们的首要任务。他还有许多其他医疗问题，如血小板减少、凝血指标紊乱、陈旧性脑梗死伴偏瘫、癫痫发作和心律失常，这些都使治疗计划变得复杂。在与患者家属讨论风险和益处后，进行了超声引导下活检，随后对SVC进行支架置入。但是，由于凝血指标紊乱，他活检部位出血。同样由于这个原因，未给他使用任何抗凝剂。24小时内支架被血栓堵塞，这通过临床特征恶化和重复CT扫描得以诊断。然后给他使用治疗剂量的依诺肝素，血栓在一天内清除，可能部分归因于依诺肝素，部分归因于凝血功能障碍。
在患有GVHD的骨髓移植患者中，相关并发症可能会混淆SVC综合征的诊断。医生必须高度怀疑，因为即使患者因其他因素如纵隔淋巴结病而患有凝血功能障碍，SVC综合征仍可能发生。即使患者有凝血功能障碍，SVC支架也可能形成血栓。因此，建议推迟进行纵隔淋巴结活检等侵入性诊断程序，直到SVC支架置入后患者病情充分稳定，因为这将避免进一步使用抗凝剂。依诺肝素可能有助于治疗此类有多种并发症患者的支架血栓形成。
