›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