A Rare Case of Fatal Pulmonary Embolism in a Pediatric Spine Surgery

Surgical treatment for pelvic haemophilic pseudotumour: a retrospective analysis of 21 cases

Background

Due to the rarity of pelvic haemophilic pseudotumour (PHPT) and demanding surgical technique for PHPT excision, no study reports the mid-term follow-up outcomes of surgical treatment of PHPT in a relatively large cohort. PHPT with varying degrees of bony pelvic involvement and infection status necessitates different operative procedures, yet there is currently no classification system for PHPT based on surgical practice.

Methods

The study was conducted between June 25, 2004 and July 18, 2023, in Peking Union Medical College Hospital and Nanfang Hospital in China. We performed a retrospective analysis involving 21 patients with 24 PHPTs with a mean follow-up period of 7.1 years. The demographic information, PHPT characteristics, surgical data, and perioperative complications were analysed.

Findings

21 consecutive male patients with 24 PHPTs (21 primary PHPTs and three recurrent PHPTs) that underwent surgical treatment were involved in the study. A classification system including four subtypes was introduced as (I) PHPT confined to soft tissue; (II) PHPT involving bony pelvic without pelvic discontinuity; (III) PHPT causing pelvic discontinuity; (IV) Infectious PHPT. Of the 24 PHPTs, 11 (45.8%) were identified as Type I, five (20.8%) as Type II, three (12.5%) as Type III, and five (20.8%) as Type IV. At the time of surgery, the patients had a mean age of 37.0 ± 9.5 years (Range, 24-52 years). The mean maximum diameter of PHPTs upon surgery was 17.0 ± 7.7 cm (Range, 4.3-40.0 cm). The mean surgical duration was 192 ± 77 min (Range, 60-330 min) and the median intraoperative blood loss was 400 mL (IQR, 225-950 mL, Range, 100-3000 mL). One patient (4.8%) underwent intraoperative cardiopulmonary arrest and expired the following week. Four PHPTs (16.7%) presented postoperative wound infections and poor wound healing. During the follow-up period, five PHPTs (20.8%) experienced pseudotumour recurrence.

Interpretation

Our findings suggest that surgical treatment for PHPTs is feasible and relatively safe. Symptomatic and progressive PHPTs should undergo surgical intervention as early as possible to minimise the surgical risks. Intraoperative use of abundant gelatin sponges in PHPT excision draws attention to severe embolism complications.

Funding

There are no sources of funding for this manuscript.

Pulmonary embolism following the third thoracic tuberculosis surgery: A case report and literature review

Background

The study aimed to analyze the clinical effects of pulmonary embolism succeeding a third surgery conducted for multiple recurrences in thoracic tuberculosis (TB).

Case report

A 74‐year‐old female patient developed thoracic tuberculosis and was subsequently treated in our hospital in March 2019, October 2020, and February 2021. The third surgical intervention included anterolateral thoracic lesion resection, internal fixation, posterior spinal tuberculous sinus resection, and debridement with suture. The operative time was 172 min resulting in a substantial intraoperative blood loss (2321 ml). Postoperative re‐examination of chest CTPA indicated a strip filling defect and pulmonary embolism in the external branch of the right middle lobe of the lung. After completing the active treatment, the D‐dimer quantification, WBC, CRP, and ESR values were 1261 ng/ml, 7.71 × 10⁹/L, 74.66 mg/L, and 63 mm, respectively. Chest CTPA re‐examination after the treatment showed no signs of pulmonary embolism.

Conclusion

Patients with a long‐term history of multiple operations, high BMI, cerebral infarction, diabetes, and older age group were more likely to develop pulmonary embolism after spinal tuberculosis surgery. Thus, the possibility of postoperative pulmonary embolism should be thoroughly analyzed before any subsequent surgical treatment in patients with recurrent spinal tuberculosis.

Review of topical gelatin-based haemostatic agents; an insidious culprit of intraoperative anaphylaxis?

BACKGROUND

An under-recognized complication of gelatin-based haemostatic agents is their potential to cause anaphylactic reactions. This review aims to collate and analyse case in the literature of intraoperative anaphylaxis secondary to locally applied haemostatic agents.

METHODS

An electronic search was performed on databases Medline, Embase, Pubmed and ProQuest. A total of 7671 articles were reviewed from title and abstract. After exclusion criteria and duplicates removed, 19 articles with 21 cases were included for analysis. Data extracted from each of the articles included patient demographics, haemostatic agent used, surgery type, known allergies and any objective evidence of hypersensitivity post anaphylactic episode, that is tryptase levels, IgE levels, skin prick testing.

RESULTS

Fifty-seven percent of cases involved patients <18 years of age; 57% of cases involved spinal surgery; 100% of cases displayed objective evidence of hypersensitivity (tryptase levels, bovine or porcine IgE levels, or skin prick testing). Thirty-three percent of patients had exposure preoperatively to a known agent causing anaphylaxis or allergy which would preclude the use of a gelatin-based haemostat. These products included vaccines, spam meats, red meat, Jell-O and CollaPlug. Gelatin-based haemostat agents included Floseal, Gelfoam, Surgiflo, fibrin glue, Avitene, haemofibrine sponge, topical bovine thrombin and thrombin-soaked gelatin.

CONCLUSION

Increased awareness of allergy to gelatin-based haemostats for surgical and anaesthetic is imperative, with 33% of cases having a known contraindication to gelatin-based haemostat. This review highlights important aspects in the pre-operative patient history and post-event patient investigation that could assist anaesthetists and surgeons in the prevention of future events.

Gas Embolism After Hydrogen Peroxide Use During Spine Surgery: Case Report and Literature Review

BACKGROUND

As an irrigant, an antiseptic, and a hemostatic agent, hydrogen peroxide (H₂O₂) is widely used in surgical treatment, but it has been surrounded by persistent controversy. Fatal or near-fatal embolic events caused by H₂O₂ have been reported sporadically in spine surgery.

CASE DESCRIPTION

In this report, we present an 87-year-old man who underwent lumbar instrumentation removal and debridement consequent to surgical site infection in a prone position. H₂O₂ was used to irrigate the infected screw tracks and surrounding tissues during the procedures. Soon after irrigation, the patient suddenly developed tachycardia, hypotension, and rapid oxygen desaturation, followed by bradycardia. Transesophageal echocardiography indicated gas embolism. After prompt first aid treatment, the patient's condition improved and the gas embolus disappeared within a few minutes without any evidence of organ embolism.

CONCLUSIONS

Spine surgeons should reconsider the pending results of using H₂O₂ during surgery. Prolonged prone positioning and semiclosed cavities may increase the risk of gas embolism. An early diagnosis and timely intervention may be the key measures to prevent the occurrence of fatal consequences caused by gas embolism.