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Li Z, Cai N. Successful cardiopulmonary resuscitation of cardiac arrest induced by massive pulmonary embolism under general anesthesia: a case report. Front Cardiovasc Med 2023; 10:1164076. [PMID: 37424914 PMCID: PMC10324405 DOI: 10.3389/fcvm.2023.1164076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2023] [Accepted: 05/31/2023] [Indexed: 07/11/2023] Open
Abstract
Background While pulmonary embolism (PE) is a common occurrence, a large life-threatening PE is not. Herein, we discuss the case of a patient with a life-threatening PE that occurred under general anesthesia. Case presentation We present the case of a 59-year-old male patient who was at bed rest for several days due to trauma, which resulted in femoral and rib fractures and a lung contusion. The patient was scheduled for femoral fracture reduction and internal fixation under general anesthesia. After disinfection and surgical towel laying, there was a sudden occurrence of severe PE and cardiac arrest; the patient was successfully resuscitated. Computed tomography pulmonary angiography (CTPA) was performed to confirm the diagnosis, and the patient's condition improved after thrombolytic therapy. Unfortunately, the patient's family eventually discontinued treatment. Discussion Massive PE frequently occurs suddenly, may endanger a patient's life at any point in time, and cannot be diagnosed quickly on the basis of clinical manifestations. Although the vital signs fluctuate greatly and there is insufficient time to conduct more tests, some factors such as special disease history, electrocardiography, end-tidal carbon dioxide, and blood gas analysis may help us determine the preliminary diagnosis; however, the final diagnosis is made using CTPA. Current treatment options include thrombectomy, thrombolysis, and early anticoagulation, of which thrombolysis and early anticoagulation are the most feasible. Conclusion Massive PE is a life-threatening disease that requires early diagnosis and timely treatment to save patients' lives.
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Chen K, Liu Z, Li Y, Zhao X, Zhang S, Liu C, Zhang H, Ma L. Diagnosis and treatment strategies for intraoperative pulmonary embolism caused by renal tumor thrombus shedding. J Card Surg 2022; 37:3973-3983. [PMID: 35998277 DOI: 10.1111/jocs.16874] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Revised: 08/01/2022] [Accepted: 08/08/2022] [Indexed: 11/29/2022]
Abstract
AIM To provide an overview of techniques for prevention, immediate diagnosis, and treatment strategies of intraoperative pulmonary embolism caused by renal tumor thrombus shedding. METHODS A total of 290 patients admitted into our medical center from March 2015 to May 2021 were retrospectively analyzed. All patients underwent radical nephrectomy with tumor thrombectomy. Six patients were diagnosed as pulmonary embolism during the perioperative period, of which two patients had tumor thrombus shedding. One patient underwent thoracotomy and thrombectomy, one patient underwent interventional thrombectomy, and four patients underwent conservative treatment. All patients have gone through our diagnosis and strategy flow chart. Demographic data, tumor characteristics, tumor thrombus characteristics, and follow-up data were collected. RESULTS In the preoperative risk factor assessment, of the 253 patients who entered the follow-up, 163 were women, 48 were older than 60 years old, and 83 had a duration of more than 2 months. In addition, 27 patients had tumor thrombus with bland thrombus, and 43 patients had floating tumor thrombus. 78 patients underwent postoperative anticoagulation after evaluation. The average follow-up time was 23.3 ± $\pm $ 8.6 months (range, 7-31 months). All patients were alive during the follow-up period. CONCLUSION For acute pulmonary embolism during nephrectomy and tumor thrombectomy, management strategies can be used to deal with intraoperative emergencies and provide reference.
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Affiliation(s)
- Kewei Chen
- Department of Urology, Peking University Third Hospital, Beijing, China
| | - Zhuo Liu
- Department of Urology, Peking University Third Hospital, Beijing, China
| | - Yuxuan Li
- Department of Urology, Peking University Third Hospital, Beijing, China
| | - Xun Zhao
- Department of Urology, Peking University Third Hospital, Beijing, China
| | - Shudong Zhang
- Department of Urology, Peking University Third Hospital, Beijing, China
| | - Cheng Liu
- Department of Urology, Peking University Third Hospital, Beijing, China
| | - Hongxian Zhang
- Department of Urology, Peking University Third Hospital, Beijing, China
| | - Lulin Ma
- Department of Urology, Peking University Third Hospital, Beijing, China
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Hsu PY, Wu EB. Anesthetic management for intraoperative acute pulmonary embolism during inferior vena cava tumor thrombus surgery: A case report. World J Clin Cases 2022; 10:5111-5118. [PMID: 35801013 PMCID: PMC9198887 DOI: 10.12998/wjcc.v10.i15.5111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Revised: 03/01/2022] [Accepted: 03/26/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Acute pulmonary embolism (APE) is a rare and potentially life-threatening condition, even with early detection and prompt management. Intraoperative APE required specific ways for detecting since classic symptoms of APE in the awake patient could not be observed or self-reported by the patient under general anesthesia.
CASE SUMMARY A 44-year-old man with a history of hepatic cell carcinoma was admitted for radical nephrectomy and tumor thrombectomy due to a newly found kidney tumor with inferior vena cava (IVC) tumor thrombus. APE that occurred during tumor thrombectomy with hypercapnia and desaturation. The capnography combined with the transesophageal echocardiography (TEE) provided a crucial differential diagnosis during the operation. The patient was continuously managed with aggressive intravenous fluid resuscitation and blood transfusion under continuous cardiac output monitoring to maintain hemodynamic stability. He completed the surgery under stable hemodynamics and was extubated after percutaneous mechanical thrombectomy by a certified cardiologist. There were no significant symptoms and signs or obvious discomfort in the patient’s self-report during visits to the general ward.
CONCLUSION Under general anesthesia for IVC tumor thrombus surgery, a sudden decrease in end-tidal carbon dioxide is the initial indicator of APE, which occurs before hemodynamic changes. When intraoperative APE is suspected, TEE is useful in the diagnosis and monitoring before computer tomography pulmonary angiogram. Timely clinical impression and supportive treatment and intervention should be conducted to obtain a better prognosis.
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Affiliation(s)
- Pei-Yu Hsu
- Department of Anesthesiology, China Medical University Hospital, China Medical University, Taichung 404, Taiwan
| | - En-Bo Wu
- Department of Anesthesiology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 833, Taiwan
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Kim JH, Lim H, Kim HM, Lim JA. Intraoperative development of pulmonary thromboembolism in a bedridden patient owing to a pelvic bone fracture with negative preoperative computed tomography pulmonary angiographic findings: A case report. Medicine (Baltimore) 2021; 100:e26658. [PMID: 34398025 PMCID: PMC8294909 DOI: 10.1097/md.0000000000026658] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2021] [Accepted: 06/28/2021] [Indexed: 01/04/2023] Open
Abstract
RATIONALE Pulmonary thromboembolism (PTE) is a potentially life-threatening condition with high morbidity and mortality, and computed tomographic pulmonary angiography (CTPA) is an important diagnostic tool for patients in whom PTE is suspected; however, intraoperative PTE is very difficult to diagnose and often has a rapid clinical course. We experienced a case of intraoperative PTE with persistent tachycardia refractory to conventional treatments despite negative preoperative CTPA findings. PATIENT CONCERNS A 53-year-old man with a pelvic bone fracture who had been on bed rest for 10 days underwent open reduction and internal fixation under general anesthesia. He remained tachycardic (heart rate of 120 beats/min) despite treatments with fluid resuscitation, analgesics, and beta-blockers. DIAGNOSES Preoperative CTPA, computed tomography (CT) venography, and transthoracic echocardiography showed no signs of deep vein thrombosis and PTE. However, the levels of D-dimer were elevated. After the start of the surgery, tachycardia (heart rate between 100 and 110 beats/min) could not be treated with fluid resuscitation. Systolic blood pressure was maintained between 90 and 100 mm Hg using continuous infusion of phenylephrine. Ninety minutes after the surgery, systolic and diastolic blood pressures suddenly dropped from 100/60 to 30/15 mm Hg with a decrease in end-tidal carbon dioxide concentration from 29 to 13 mm Hg and development of atrial fibrillation. Arterial blood gas analysis revealed hypercapnia. Under the suspicion of PTE, cardiopulmonary resuscitation (CPR) was immediately initiated. Three CPR cycles raised the blood pressure back to 90/50 mm Hg with sinus tachycardia (115 beats/min). Transesophageal echocardiography showed right ventricular dysfunction and paradoxical septal motion. However, emboli were not found. Postoperative chest CT revealed massive PTE in both pulmonary arteries. INTERVENTIONS Immediately, surgical embolectomy was performed uneventfully. OUTCOMES The patient was discharged from the hospital 1 month later without any complications. LESSONS The patient with moderate risk for PTE (heart rate > 95 beats/min and immobilization, surgery under general anesthesia, and lower limb fracture within 1 month) should be closely monitored and managed intraoperatively even if preoperative CTPA findings are negative. The development of PTE needs to be expected if tachycardia is refractory to conventional treatments.
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Affiliation(s)
- Jong Hae Kim
- Department of Anesthesiology and Pain Medicine, School of Medicine, Daegu Catholic University
| | - Hyungseop Lim
- Department of Anesthesiology and Pain Medicine, School of Medicine, Daegu Catholic University
| | - Hyun Mi Kim
- Department of Obstetrics and Gynecology, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Jung A. Lim
- Department of Anesthesiology and Pain Medicine, School of Medicine, Daegu Catholic University
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Holland R, Houten JK, Elsamragy S, Kim J, Leyvi G, Kinon MD. Intraoperative Thrombolysis of Massive Pulmonary Embolus During Spine Surgery: Case Report of Survival Complicated by Massive Bleeding and Review of the Literature. World Neurosurg 2020; 146:59-63. [PMID: 33059081 DOI: 10.1016/j.wneu.2020.10.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 10/03/2020] [Accepted: 10/05/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Pulmonary embolism (PE) is a known risk of lumbar spinal fusion surgery that can lead to sudden and unexpected death. Treatment often involves systemic anticoagulation when the risk of potentially fatal hemodynamic deterioration is judged to outweigh the risk of epidural hematoma and paralysis. Acute massive PE with obstruction of more than 50% of the pulmonary arterial tree causes right heart failure, hypotension, and often rapid death, and may require aggressive medical intervention with thrombolytic agents, such as alteplase, although in the postoperative period this entails an extremely high risk of bleeding and the associated potential neurologic morbidity. CASE DESCRIPTION We report the first case, to our knowledge, of intraoperative thrombolytic therapy during spine surgery in a 68-year-old woman who developed a massive PE with cardiac arrest while undergoing lumbar instrumented fusion surgery in the prone position and detail the postoperative course that was complicated by severe bleeding. CONCLUSIONS Our experience is that chemical thrombolysis can be a lifesaving option to address pending circulatory arrest, but that severe bleeding is a likely consequence. If used to treat an intraoperative emergency, a smaller than standard dose of thrombolytic should be considered.
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Affiliation(s)
- Ryan Holland
- Leo M. Davidoff Department of Neurosurgery, Albert Einstein College of Medicine, Bronx, New York, USA.
| | - John K Houten
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell and Maimonides Medical Center, Brooklyn, New York, USA
| | - Shahenaz Elsamragy
- Department of Anesthesiology, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Jinu Kim
- Department of Anesthesiology, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Galina Leyvi
- Department of Anesthesiology, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Merritt D Kinon
- Leo M. Davidoff Department of Neurosurgery, Albert Einstein College of Medicine, Bronx, New York, USA
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Porres-Aguilar M, Rivera-Lebron BN, Anaya-Ayala JE, León MCGD, Mukherjee D. Perioperative Acute Pulmonary Embolism: A Concise Review with Emphasis on Multidisciplinary Approach. Int J Angiol 2020; 29:183-188. [PMID: 33149540 PMCID: PMC7599112 DOI: 10.1055/s-0040-1709501] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Perioperative acute pulmonary embolism represents a relatively rare complication; however, it could be very serious and devastating in some cases. Its diagnosis could be particularly challenging, especially in the intraoperative period. Herein, we emphasize some key concepts with the aim to perform an early and appropriate risk stratification, diagnostic and therapeutic approach in a multidisciplinary fashion, a brief overview on thromboprophylaxis, with the main objective to improve outcomes and survival in these challenging patients.
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Affiliation(s)
- Mateo Porres-Aguilar
- Division of Adult Thrombosis Medicine, McGill University/Centre of Excellence of Thrombosis and Anticoagulation Care (CETAC), Jewish General Hospital, Montreal, Quebec, Canada
| | - Belinda N. Rivera-Lebron
- Division of Pulmonary and Critical Care Medicine, University of Pittsburgh Medical Center (UPMC), Pittsburgh, Pennsylvania
| | - Javier E. Anaya-Ayala
- Section of Vascular Surgery and Endovascular Therapy, Department of Surgery, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán (INCMNSZ), Ciudad de México, México
| | - María Cristina Guerrero de León
- Department of Internal Medicine and Intensive Care Unit; Hospital de Ginecologia y Obstetricia; UMAE 23; Instituto Mexicano del Seguro Social (IMSS); Monterrey, Mexico
| | - Debabrata Mukherjee
- Division of Cardiovascular Diseases, Texas Tech University Health Sciences Center, El Paso, Texas
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Smeltz AM, Kolarczyk LM, Isaak RS. Update on Perioperative Pulmonary Embolism Management: A Decision Support Tool to Aid in Diagnosis and Treatment. Adv Anesth 2018; 35:213-228. [PMID: 29103574 DOI: 10.1016/j.aan.2017.08.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Pulmonary embolism (PE) affects up to 1 in every 1000 people per year, one-third of whom do not survive. Moreover, perioperative presentation of PE is 5 times more likely than at other times and poses a unique set of challenges for both diagnosis and treatment. This article discusses several important aspects regarding the prevention, diagnosis, and management of perioperative PE, incorporating information from the most recent practice guidelines, emerging literature on medical therapy, and interventional therapies. It proposes a clinical decision support tool that organizes the salient aspects of perioperative PE management to serve as an aid in practice.
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Affiliation(s)
- Alan M Smeltz
- Department of Anesthesiology, University of North Carolina at Chapel Hill School of Medicine, N2198 UNC Hospitals, CB 7010, Chapel Hill, NC 27599, USA
| | - Lavinia M Kolarczyk
- Department of Anesthesiology, University of North Carolina at Chapel Hill School of Medicine, N2198 UNC Hospitals, CB 7010, Chapel Hill, NC 27599, USA
| | - Robert S Isaak
- Department of Anesthesiology, University of North Carolina at Chapel Hill School of Medicine, N2198 UNC Hospitals, CB 7010, Chapel Hill, NC 27599, USA.
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Perioperative Management of the Adult Patient on Venovenous Extracorporeal Membrane Oxygenation Requiring Noncardiac Surgery. Anesthesiology 2018; 128:181-201. [DOI: 10.1097/aln.0000000000001887] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Abstract
The use of venovenous extracorporeal membrane oxygenation is increasing worldwide. These patients often require noncardiac surgery. In the perioperative period, preoperative assessment, patient transport, choice of anesthetic type, drug dosing, patient monitoring, and intraoperative and postoperative management of common patient problems will be impacted. Furthermore, common monitoring techniques will have unique limitations. Importantly, patients on venovenous extracorporeal membrane oxygenation remain subject to hypoxemia, hypercarbia, and acidemia in the perioperative setting despite extracorporeal support. Treatments of these conditions often require both manipulation of extracorporeal membrane oxygenation settings and physiologic interventions. Perioperative management of anticoagulation, as well as thresholds to transfuse blood products, remain highly controversial and must take into account the specific procedure, extracorporeal membrane oxygenation circuit function, and patient comorbidities. We will review the physiologic management of the patient requiring surgery while on venovenous extracorporeal membrane oxygenation.
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Abstract
PURPOSE OF REVIEW Anesthesiologists are familiar with pulmonary emboli prophylaxis paradigms and many have witnessed acute intraoperative embolization. Clinicians must balance conservative anticoagulation and aggressive intervention in perioperative submassive pulmonary emboli, yet the bulk of the literature excludes surgery as a relative contraindication. This review will summarize the current treatment options for acute pulmonary emboli, drawing attention to special considerations in perioperative submassive pulmonary emboli, and discuss right ventricular monitoring to improve assessment of intervention efficacy. RECENT FINDINGS Recent reviews have identified the elevated risk and inadequacy of treatment of pulmonary embolism in intra and postoperative patients, in part because of the risks of systemic anticoagulation. Early studies of catheter-directed therapies have shown promising efficacy with a reduction in bleeding risk, which is especially important for perioperative patients. Success relies on defining endpoints, yet the practice of measuring mean pulmonary artery pressure alone to assess intervention efficacy is flawed. SUMMARY Identifying submassive pulmonary emboli that requires treatment and optimizing therapy remains difficult. Researchers must consider avoiding systemic anticoagulation and focus on designing trials that evaluate intervention efficacy in surgical patients. The success of catheter-directed therapy in early trials warrants further investigation into using these therapies in the treatment of perioperative submassive pulmonary emboli.
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The periprostatic venous plexus: an unusual source of fatal pulmonary embolism during corporoplasty. Int J Legal Med 2016; 131:713-717. [PMID: 28004195 DOI: 10.1007/s00414-016-1519-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2016] [Accepted: 12/15/2016] [Indexed: 10/20/2022]
Abstract
When a sudden death occurs during a minor surgical intervention, it may require a careful and extensive postmortem investigation. One such case concerns a 61-year-old male patient affected by Peyronie's disease, who died suddenly during a corporoplasty procedure. Autopsy and histologic examinations showed a massive bilateral pulmonary micro-embolism brought on by periprostatic venous plexus thrombosis. The cause of death was attributed to intraoperative fatal pulmonary micro-embolism. Pulmonary thromboembolism is a major cause of death and is known to be a possible complication of surgery. Nevertheless, the periprostatic venous plexus is an unusual site of thrombosis, as it has been demonstrated that the majority of emboli originate in the legs. In this case, the embolism was massive and fatal and occurred during a minor surgical procedure, even though the patient was not at risk for venous thromboembolism, nor did he have a significant past medical history.
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