Hemodynamic-Protective Anesthesia for Emergency Rigid Esophagoscopy in an Adult with Uncorrected Pulmonary Atresia with Ventricular Septal Defect, Aortopulmonary Collaterals, and Pneumonia: A Case Study

Abstract

Background. Adult survivors of uncorrected pulmonary atresia with ventricular septal defect (PA-VSD) depend on aortopulmonary collaterals, and a fall in systemic vascular resistance can increase right-to-left shunting. Emergency shared-airway esophagoscopy adds risks of aspiration, bleeding, and anticoagulation.

Objective. To describe the anesthetic management, hemodynamic course, and outcome of an adult with uncorrected PA-VSD, active pneumonia, and warfarin anticoagulation who needed emergency rigid esophagoscopy for an impacted denture.

Methods. This single case report follows the CARE guideline. A 51-year-old man (56 kg; ASA IV-E) presented four hours after swallowing a partial denture lodged at C4–C5. His cardiac index was 1.86 L/min/m², and Klebsiella pneumoniae pneumonia was present. Over four hours, fresh frozen plasma (10 mL/kg) and vitamin K lowered the INR from 2.60 to 1.42. Anesthesia used modified rapid sequence induction (etomidate, fentanyl, rocuronium), sevoflurane, a phenylephrine infusion, lung-protective ventilation, and invasive monitoring.

Results. At +30 minutes, mean arterial pressure (MAP) fell to 58 mmHg with SpO₂ 88%, and recovered to 68 mmHg within 90 seconds of a phenylephrine bolus (100 mcg). Thereafter MAP was 68–76 mmHg and SpO₂ 92–94%. The denture was removed en bloc after 22 minutes of manipulation, with 50 mL blood loss and no mucosal perforation. The patient was extubated on postoperative day 1 and discharged on day 8.

Conclusion. In this patient, early INR correction, etomidate-based induction, phenylephrine support, and normocapnic lung-protective ventilation accompanied an uncomplicated course. One case cannot show causation; larger series are needed.