Endobronchial hemorrhage after intubation with double-lumen endotracheal tube in a patient with idiopathic thrombocytopenic purpura for minimally invasive cardiac surgery: a case report

Abstract

Minimally invasive cardiac surgery (MICS) requires lung isolation. Lung isolation is usually achieved with double-lumen endotracheal tube (DLT). Patients with idiopathic thrombocytopenic purpura (ITP) have an increased risk of bleeding events. We suspected endobronchial hemorrhage after exchange of DLT during induction of anesthesia for replacement of mitral valve in a 62-year-old man with a known ITP. The MICS was stopped and bronchial artery embolization was performed in the angiographic room. In the present case, in order to reduce the risk of bronchial arterial injury in ITP patient we intubated with single lumen endotracheal tube. Lung isolation led to achievement of intermittent total lung deflation. Based on the results, we recommend a high-dose intravenous immunoglobulin therapy and platelet transfusion prior to cardiac surgery in patients with ITP to increase platelet count. Moreover, it is proposed that in order to clear the vision during the operation, ventilation can be held or made intermittent both prior to cardiopulmonary bypass or at its conclusion to permit exposure.

Comparison of the single-lumen endotracheal tube and double-lumen endobronchial tube used in minimally invasive cardiac surgery for the fast track protocol

“…Intubation with a SLT has been started because of failed intubation with a DLT undergoing MICS in our department. Also we had experienced a case of endobronchial bleeding while using a DLT in patients with idiopathic thrombocytopenic purpura (5). Although there was a bronchial blocker (BB) in our hospital, we did not use it because it needs more time to be positioned, more often repositioning, and provides nonoptimal right lung isolation due to right upper lobe anatomy (11).…”

“…Moreover, there are specific conditions in which a SLT may be preferred to a DLT, such as patients with previous oral or neck surgery who present with a challenging airway and require lung separation. Although one lung ventilation is important but not essential for MICS if it is possible that ventilation can be held or made intermittent both prior to CPB or at its conclusion to permit exposure (5).…”