Diagnostic and therapeutic challenges n a critically ill patient in icu with uperior vena cava syndrome

Pragny Adipta Mishra, Rajini Kausalya, Rajiv Jain

Research output: Contribution to journalArticle

Abstract

Purpose To highlight the diagnostic and therapeutic challenges associated with the treatment of a patient with superior vena cava syndrome and a coexisting coagulopathy. Clinical features 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. Conclusion 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.

Original languageEnglish
Pages (from-to)105-110
Number of pages6
JournalMiddle East Journal of Anesthesiology
Volume21
Issue number1
Publication statusPublished - Feb 2011

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Venae Cavae
Critical Illness
Superior Vena Cava Syndrome
Enoxaparin
Superior Vena Cava
Stents
Therapeutics
Graft vs Host Disease
Biopsy
Anticoagulants
Pneumonia
Lymph Nodes
Bone Marrow
Transplants
Hemiplegia
Bronchiectasis
Delayed Diagnosis
Cerebral Infarction
Thrombocytopenia
Intensive Care Units

ASJC Scopus subject areas

  • Anesthesiology and Pain Medicine

Cite this

Diagnostic and therapeutic challenges n a critically ill patient in icu with uperior vena cava syndrome. / Mishra, Pragny Adipta; Kausalya, Rajini; Jain, Rajiv.

In: Middle East Journal of Anesthesiology, Vol. 21, No. 1, 02.2011, p. 105-110.

Research output: Contribution to journalArticle

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