› Symptom mitigation
› Upright positioning
› Avoid supine
› Sleep with head elevated
› Oxygen therapy
› Titrate to SpO2 92-96%
› Fluid strategy
› Avoid aggressive fluids unless hypotension
› Diuresis only if volume overload
› Access strategy
› Femoral venous access
› Avoid upper extremity infusion when possible
Airway and Cerebral Edema Management
› High risk airway approach
› If stridor, early expert airway
› Awake fiberoptic intubation preferred
› Avoid paralytic induced loss of airway tone if possible
› If emergent airway, prepare surgical airway backup
› ENT at bedside if available
› Cricothyrotomy equipment ready
› Cerebral edema adjuncts
› Dexamethasone IV 10 mg once then 4 mg IV every 6 hours
› Preferred when lymphoma suspected
› Potential to obscure lymphoma histology
› Hypertonic saline 3% 2 ml/kg IV bolus for severe neurologic symptoms
› Serum sodium target 145-155 mmol/l
› Avoid in chronic hyponatremia without close monitoring
Anticoagulation and Thrombosis Therapy
› Catheter associated thrombosis
› Initiate anticoagulation if no contraindication
› Unfractionated heparin infusion
› Bolus 80 units/kg IV
› Infusion 18 units/kg/hour
› Titrate to institutional aPTT target
› Enoxaparin 1 mg/kg SC every 12 hours
› Avoid if CrCl severely reduced
› Catheter management
› If line no longer needed, remove after anticoagulation initiated
› If line needed, maintain with anticoagulation unless infected
› Thrombolysis considerations
› If acute onset under 14 days and severe symptoms, catheter directed thrombolysis via interventional radiology
› Intracranial hemorrhage and recent surgery as major contraindications
› SVC stenting
› Indications
› Severe symptoms
› Rapid progression
› Need for immediate relief prior to tissue diagnosis
› Expected response
› Symptom improvement within 24-72 hours
› Often within hours
› Periprocedural considerations
› Contrast nephropathy risk mitigation
› Anticoagulation or antiplatelet regimen per interventional radiology protocol
› Evidence level framing
› Endovascular stent as first line for severe malignant SVCS supported by expert consensus Class I recommendation
› Radiation therapy
› Indications
› Radiosensitive tumor with confirmed or strongly suspected diagnosis
› Non stent candidates
› Limitations
› Slower symptom relief than stent
› Risk of obscuring future biopsy yield in some settings
› Chemotherapy
› Indications
› Small cell lung carcinoma
› Lymphoma
› Coordination
› Oncology led regimen selection
› Tumor lysis prevention planning when high burden suspected
› Steroids role
› Dexamethasone IV regimen for suspected lymphoma as above
› Use after biopsy plan clarified when feasible
› Earlier use when airway or cerebral compromise present
› Diuretics role
› Limited evidence for venous obstruction relief
› Use only for concomitant heart failure or volume overload
› Furosemide 20-40 mg IV once
› Analgesia and anxiolysis
› Avoid heavy sedation in airway risk
› Small incremental doses if needed
› Continuous monitoring
Show 53 more ▾