Episode #81 Massive Hemoptysis in the CT-Suite

January 18, 2022

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Welcome to the next installment of the Anesthesia Patient Safety podcast hosted by Alli Bechtel.  This podcast will be an exciting journey towards improved anesthesia patient safety.

Today, we return to our off-site, NORA location to continue our discussion related to the article, “Massive Hemoptysis – A Rare but Catastrophic Complication” by Candance Chang and Nathaniel Richins.

Here is the sample Emergency Response Protocol following Massive Hemoptysis:

TABLE 1. Massive Hemoptysis Protocol for CT/IR

  • Activate Staff Assist button in CT (alerts IR, OR, Anesthesia Professional and Technicians)
  • Call IR support “Bring code cart to CT”
  • Call Emergency Anesthesia Professional
  • Call Anesthesia Technician to bring massive hemoptysis toolbox
  • Call Thoracic Surgery
  • Call Pulmonology
  • Call blood bank for emergency release blood
  • Call ICU
  • Do NOT hit Code Blue button unless specifically instructed to do so
  • One person assigned to continuous suction.
  • Quick CT to visualize hemorrhage.
  • Bring patient out of scanner, move to stretcher supine for intubation.
  • Bring portable monitor in case vital signs are difficult to see due to CT scanner obstructing view.
  • Place large bore IV.
  • Emergent intubation supine, mainstem intubate contralateral side to biopsy if possible.
  • After patient intubated, lung isolation by mainstem intubation, bronchial blocker, or double lumen tube. Consider jet ventilation if lung isolation not possible.
  • Position patient with bleeding side DOWN if lungs are not isolated, biopsy side UP if lung isolation achieved.
  • Add maximal PEEP to the ventilator or bag valve mask to reduce bleeding.
  • Anesthesia technician to bring (in this order)-
    • Video laryngoscope and fiberoptic bronchoscope
    • Massive hemoptysis toolbox (8.0/8.5 mm ETTs, airway exchange catheter, bag mask with PEEP valve, bronchial blocker, surgical airway kit, intubating LMA 3/4/5, suction catheters 14/18 Fr., 37/39 Fr. left double lumen tubes)
    • IV set up (normal saline liter bag with blood transfusion tubing)
    • Jet ventilator
    • Arterial line pressure bag set up and transducer
    • Rapid infuser
  • IR physician to place femoral arterial line first, then venous line if large bore IV not
  • obtained yet.
  • Draw type and cross sample from new IV or one of the femoral lines.
  • Anesthesia technician to set up blood transfusion tubing.
  • Send runner to get blood from blood bank (may need emergency release blood).
  • IR, Pulmonology, and Thoracic Surgery to discuss definitive treatment of bleeding.
  • Possible transfer to ICU for stabilization if hemorrhage is not severe.

Abbreviation legend:
CT: Computed tomography
IR: Interventional Radiology
IV: Intravenous
OR: Operating Room
ICU: Intensive Care Unit
Fr: French

Calling all researchers dedicated to improving anesthesia patient safety and preventing morbidity and mortality from anesthesia mishaps! Letters of Intent for the APSF Investigator Initiated Research Grants are due by February 17, 2022. The awards are made to the sponsoring institution for up to $150,000 for 2 years duration for 10-30% research time depending on the project.

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© 2022, The Anesthesia Patient Safety Foundation

Hello and welcome back to the Anesthesia Patient Safety Podcast.  My name is Alli Bechtel, and I am your host. Thank you for joining us for another show. Once again, we are leaving the operating rooms and heading over, up or down to non-operating room anesthesia sites, where we left off last week. So, let’s go!

Before we dive into the episode today, we’d like to recognize ICU Medical, a major corporate supporter of APSF. ICU Medical has generously provided unrestricted support to further our vision that “no one shall be harmed by anesthesia care”. Thank you, ICU Medical – we wouldn’t be able to do all that we do without you!”

We made it to the non-operating room anesthesia, or NORA, location and we are going to return to our discussion about the case of Massive Hemoptysis following CT guided biopsy and the implementation of an emergency response protocol. If you haven’t listened to Episode #80, go take a listen. Our featured article for today is, “Massive Hemoptysis – A Rare but Catastrophic Complication” by Candance Chang and Nathaniel Richins. To follow along with us, head over to APSF.org and click on the Newsletter heading. Second one down is Articles Between Issues. Then, scroll down until you get to August 25, 2021 and our featured article today.

We discussed the case of massive hemoptysis following CT-guided lung biopsy last week and today, we are going to start with a review of the procedure, CT Lung Biopsy. Have you provided anesthesia for a patient undergoing this procedure? Did you do a time-out prior to the anesthesia induction and procedure? If not, check out episode 80 for an example of a NORA Time-out checklist to use.

Now, let’s get back into the article. For a CT-guided lung biopsy, major complications occur at a rate of 5.7%. Hemoptysis is the most common major complication which occurred in about 4% of core lung biopsy cases from a metanalysis completed in 2016. Other complications following this procedure include pneumothorax that required treatment with manual aspiration or chest tube placement, hemothorax, air embolism, and needle tract seeding. Massive hemoptysis and severe hemorrhage is a rare event which occurs at a rate of 1.8%, but may have devastating complications. Death may occur due to blood obstructing the patient’s airway leading to inability to oxygenate and ventilate. Past mortality rates have been reported as high as 75%. The rate has decreased down to 13% because of advanced airway equipment and available interventions including surgery, bronchoscopic balloon tamponade or coagulation, and bronchial artery embolization with interventional radiology.

We have discussed the response to massive hemorrhage in the operating room on this podcast before, but the management of hemoptysis and massive hemorrhage at an off-side NORA location has additional challenges including small size of the CT suite, room layout, unfamiliar staff, far away from additional help and supplies, as well as older patients with more comorbidities. The authors highlight that general anesthesia for this procedure may be beneficial for higher risk patients to ensure a protected airway right from the beginning of the procedure. Risk factors for this complication include the following patient factors: older age, female sex, coagulopathy, and emphysema. Risk factors related to the procedure include larger biopsy needle diameter, increased distance traveled through lung parenchyma, and smaller lesion size.

Next up, we are going to discuss the protocol for emergency response to massive hemoptysis following CT-guided biopsy. Creating rapid response protocols is an important part of keeping patients safe during anesthesia care, especially for a rare event in an off-site location. The authors describe the primary goals for the protocol.

  1. “Secure the airway with a large endotracheal tube (that’s size 8.0 mm ETT or greater) and isolate the bleeding lung if possible,
  2. Obtain arterial and venous access for blood pressure monitoring and volume resuscitation,
  3. Consult specialists for definitive treatment to stop the hemorrhage.1”

The secondary goals for the protocol are additional steps to optimize treatment. If possible, position the patient with the bleeding side down if the lungs are not isolated to prevent or minimize blood from entering the other lung. Using positive end-expiratory pressure or PEEP following intubation may help to decrease the bleeding from tamponade at the side of injury. Once lung isolation has been achieved, the patient may need to be repositioned so that the bleeding side is up with optimization of ventilation and perfusion to the dependent, non-bleeding lung. The 2 priorities of the anesthesia professional’s role in the emergency response are airway management and fluid resuscitation. The role for the interventional radiologist includes obtaining femoral vascular access including venous and arterial as well as consulting with thoracic surgery and pulmonology specialists regarding chest tube placement and definitive treatment options including the following:

  • Bronchoscopic coagulation
  • Interventional radiologic embolization
  • Surgical repair
  • Stabilization and transfer to the ICU

Other members of the healthcare team are responsible for maintaining suction and calling for additional help and supplies.

Now, what about similar procedures that are performed by bronchoscopy rather than CT-guided? These patients are also at risk for major complications with reported rates of less than 1% to 5% and risk factors for pulmonary hemorrhage include malignancy, coagulopathy, and immunocompromised state. When pulmonary hemorrhage occurs following bronchoscopy, direct visualization may facilitate quick treatment with tamponade of the bleeding and appropriate lung isolation to maintain adequate oxygenation and ventilation. In the CT-suite, this may not be accomplished as easily, but gaining vascular access may be accomplished quickly by the interventional radiologists and with the available equipment.

You may have noticed that I did not mention patients with pulmonary hypertension. This is not a risk factor for hemorrhage following CT-guided biopsy or bronchoscopy.

Now, it is time to return to the protocol. Here we go.

The first section is communication which starts by

  1. Activating the Staff Assist button in CT to alert IR, OR, and Anesthesia Professionals and Technicians.
  2. Followed by calling for additional support from:
    1. IR support with the request, “Bring the code cart to CT”
    2. Emergency Anesthesia Professional
    3. Anesthesia Technicians to bring massive hemoptysis toolbox.
    4. Thoracic Surgery
    5. Pulmonology
    6. Blood Bank to release emergency blood
    7. And ICU

The next part of the protocol is the Procedure section. Here are the crucial steps.

  1. One person assigned to continuous suction.
  2. Perform a quick CT to visualize the hemorrhage.
  3. Quickly bring the patient out of the scanner and over to the stretcher for intubation.
  4. Utilize a portable monitor for vital signs if needed.
  5. Place large bore IV access. This may even need to be IO access.

The third section is related the responsibilities of the Anesthesia professionals.

  1. Perform emergent intubation with mainstem placement of endotracheal tube on the contralateral side of the biopsy and bleeding if possible. Other methods for lug isolation may be necessary including bronchial blocker or double lumen tube. If lung isolation is not successful, jet ventilation may be necessary.
  2. Position patient depending on lung isolation: If no lung isolation, bleeding side down. If lungs are isolated, bleeding side up.
  3. Add maximal PEEP in order to help decrease bleeding.
  4. Here are the supplies that the anesthesia tech will need to bring as part of this response protocol: Video laryngoscope, fiberoptic bronchoscope, Massive hemoptysis toolbox (Don’t worry, we will review the contents of the toolbox next week!), IV set up with IV fluids and blood transfusion tubing, Jet ventilator, arterial line pressure bag set up and transducer, and rapid infuser.

The final section of the protocol is hemorrhage which includes the following steps.

  1. IR physician to place femoral arterial line first, followed by large bore central venous access if not already obtained.
  2. Draw type and cross sample
  3. Anesthesia tech to set up blood transfusion tubing.
  4. Send runner to blood bank for blood to transfuse. This may need to be emergency release blood.
  5. Discussion of treatment of bleeding between IR, Pulmonology, and thoracic Surgery.
  6. Consider transfer to ICU for further stabilization for less severe hemorrhage.

An important part of creating an emergency response protocol is to debrief after critical events and solicit feedback about what went well and what modifications need to be made. The authors reveal lessons that they learned as part of this process. First, the authors had to think outside the box to tackle the challenge of fast, effective, and simple communication for the NORA location. This involved installing a special button in the CT suite next to the code blue button labeled “staff assist.” Pushing the staff assist button is the first step of the protocol and ensures that the necessary staff respond to the emergency without the entire hospital code team arriving in the small CT suite. Check out Figure 2 in the article for a picture of this button in the CT suite.

The next lesson related to the need for rapid induction of anesthesia followed by securing the airway. There is no time to delay for patients with severe hemorrhage, so get these patients out of the scanner immediately. Patients with mild hemoptysis who are still positioned in the scanner may be able to undergo quick CT scan to help determine the location and extent of the bleeding. The anesthesia professional must be focused on securing the airway with the ultimate goal of achieving lung isolation. This is where the Hemoptysis Toolbox comes in which I mentioned as part of the third section of the protocol. The toolbox includes the following: intubating LMAs for blind intubation and a cricothyrotomy kit. The anesthesia professional may need to act quickly to secure the airway with either a single lumen or double lumen tube depending on the patient’s clinical condition, airway exam, and amount of hemoptysis. Lung isolation following intubation with a single lumen endotracheal tube may be accomplished with mainstem intubation or bronchial blocker placement. Keep in mind that visualization with bronchoscopy may be difficult due to blood in the trachea, but a double lumen tube may be able to be positioned blindly after passing through the vocal cords. Another consideration is jet ventilation when lung isolation is not successful or possible. Finally, ECMO may be an option, but requires rapid mobilization of appropriate staff and supplies and the patient may need to be transported to the operating room depending on the size and location of the CT suite.

The authors discuss the lessons learned about the coordinated contributions of colleagues in other specialties during the emergency response. The interventional radiologist is an expert at obtaining vascular access and is responsible for securing femoral venous and arterial access first followed by a check tube if there is a significant hemothorax. Pulmonologists are skilled bronchoscopists and may be able to help with bronchoscopy and lung isolation to protect the non-bleeding lung as well as treatment of the site of injury with ice cold saline, tamponade, and cauterization.

Positioning the patient after securing the airway and vascular access was another lesson learned for these cases depending on the ability to isolate the lungs. Remember, if the lungs are not isolated, then position the patient bleeding lung down to prevent blood from contaminating the other lung. Once lung isolation has been achieved, position the patient with the bleeding side up to optimize ventilation/perfusion matching in the dependent lung.

An important consideration is the availability of suction in the CT suite, so extra suction may be needed for visualization of the airway and to be able to maintain ventilation and oxygenation once the airway has been secured. Therefore, there is one person in the protocol who is responsible for ensuring continuous suction is available.

Blood transfusion following a CT-guided lung biopsy is not common and may not be necessary for patients with mild hemoptysis. In cases of severe hemorrhage, emergency release blood may be needed. It is important to discuss the need for a pre-procedure type and screen with blood available for high risk patients during the time-out.

Finally, discuss the plan for treatment with other specialties early in the emergency response. The treatment may be surgical, bronchoscopic, or radiologic and the patient may need to be moved to another location for this intervention and doing so quickly and safely is imperative. You may also consider calling the critical care physicians to discuss stabilization in the ICU for mild or self-limited cases.

Thank you so much to the authors for sharing their protocol and lessons learned from this challenging case to help improve survival in the future.

If you have any questions or comments from today’s show, please email us at [email protected]. Please keep in mind that the information in this show is provided for informational purposes only and does not constitute medical or legal advice. We hope that you will visit APSF.org for detailed information and check out the show notes for links to all the topics we discussed today.

Calling all patient safety researchers dedicated to improving anesthesia patient safety and preventing morbidity and mortality from anesthesia mishaps! The Letters of Intent for the APSF Investigator Initiated Research Grants are due by February 17, 2022. The awards are made to the sponsoring institution for up to $150,000 for 2 years duration for 10-30% research time depending on the project. For more information, head over to APSF.org and check out the Grants and Awards heading, second one down is Investigator initiated research grants. I will include a link in the show notes as well. We are looking forward to your submission!!

Until next time, stay vigilant so that no one shall be harmed by anesthesia care.

© 2022, The Anesthesia Patient Safety Foundation