手術中形成的上腔靜脈症候群造成非預期的呼吸道阻塞之病例報告

ntraoperative Iatrogenic Superior Vena Cava Syndrome Complicated by Ensuing Insidious Critical Airway —~- A Case Report

大部分的上腔靜脈症候群（SVC syndrome）以典型而不易忽略的症狀表現，例如在臉部、脖子、手臂、上胸部的水腫及靜脈擴張；意識清楚的病人可能會抱怨呼吸困難及呼吸道阻塞。然而在手術過程中形成的上腔靜脈症候群因為缺乏病人主觀的抱怨及多變的臨床症狀導致不易分辨。我們描述一個在進行肺切除手術時，因醫源性損傷上腔靜脈而導致無明顯臨床症狀的上腔靜脈症候群的病人。在將雙腔氣管內管（double lumen endobronchial ube）換成一般氣管內管時，發現病人有嚴重之呼吸道水腫及阻塞。幸好經由換管前所置放之氣管內管通條，順利在血氧滾度下降時將氣管內管及時置入。接著病人呈現典型的急性上腔靜脈症候群的症狀。之後使用血栓溶解劑及抗凝劑治療，但病人仍因肺栓塞死亡。我們討論了延遲診斷可能的原因、術中處理方法、及病人的預後。

Superior vena cava (SVC) syndrome mostly presents the typical and unmistakable symptoms and signs, such as edema and venous distension of the face, neck, arms, and upper chest wall. Dyspnea and symptoms of airway ob-struction are often the complaints of conscious patients. However, SVC syndrome if develops intraoperatively may become indistinguishable in view of the lack of utterable complaints of the patient and variable degrees of clinical presentation. We present a male patient who sustained an iatrogenic sub clinical SVC syndrome in the course pneu-monectomy. Airway obstruction was initially noted during the replacement of the double lumen endobronchial tube (DLT) by an ordinary endotracheal tube at the end of operation, which threw the patient into an acute pre-carious condition. Although he was conservatively treated with thrombolytic agent and anticoagulant, the patient eventually expired due to pulmonary embolism. The possible reasons for delayed diagnosis, intraoperative man-agement, and prognosis of this case are discussed.