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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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Unicameral bone cyst: radiographic assessment of venous outflow by cystography as a prognostic index. J Pediatr Orthop B 2012; 21:489-94. [PMID: 22751482 DOI: 10.1097/bpb.0b013e328355e5ba] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/10/2023]
Abstract
The aim of this study was to determine the benefits of cystography in the management of a simple bone cyst, its implication in the final result of the treatment after corticoid intracystic injections, and the presence of secondary effects. We retrospectively reviewed 42 patients diagnosed with a simple bone cyst. Cystography was performed before the corticoid injection. The presence or absence of loculation intracyst and the existence and number of venous outflows were determined. According to the venous drainage, cysts were classified as type 0 when a venous outflow did not exist and as type 1 when there was a rapid venous outflow (<3 min). The treatment protocol included a maximum of three corticoid injections at an interval of 6 months. Healing of the cyst was determined on the basis of Neer's criteria. Secondary effects and surgical complications were assessed. Cystography studies showed a unicameral bone cyst with absent loculation in 16 cases (37.3%), whereas the lesion showed multiloculation in 26 cases (62.7%). There was no statistical difference between loculation intracyst (present or absent) and the final outcomes of the 42 cysts treated with a steroid injection (P=0.9). Cystography showed a negative venogram in 10 cases (23.8%), whereas the cysts showed a rapid venous outflow in 32 cases (76.2%). On the basis of Neer's classification, all patients with a negative venogram achieved complete healing of the cyst. Patients with a rapid venous outflow achieved complete healing in 14 cases (Neer I). In two patients, the healing was incomplete at the end of the follow-up period (Neer IV). In most cases (21 cysts), healing was partial (Neer II). Five patients showed a recurrence after initial healing of the cyst (Neer III) (P<0.05). The number or the size of veins did not affect healing of a bone cyst (P=0.6). Two patients with a rapid venous outflow showed a generalized hypertrichosis after the first injection of corticosteroids. Sex and age at the initiation of the first injection were not significant factors of healing (P=0.4). The average follow-up time was 59 months (24-60 months). Cystography provides morphological and functional information of simple bone cyst. It is a useful test before the administration of percutaneous injections of sclerosing substances. It facilitates the differentiation of cysts that may achieve complete healing (negative venogram) from those that tend to show recurrence (rapid venous outflow). Therapeutic material should be introduced slowly and a second trocar should always be placed to decrease the risk of migration in cysts with communication with the venous system.
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Perioperative pulmonary embolism: diagnosis and anesthetic management. J Clin Anesth 2011; 23:153-65. [DOI: 10.1016/j.jclinane.2010.06.011] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2009] [Revised: 06/18/2010] [Accepted: 06/29/2010] [Indexed: 12/17/2022]
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Mechanick JI, Kushner RF, Sugerman HJ, Gonzalez-Campoy JM, Collazo-Clavell ML, Spitz AF, Apovian CM, Livingston EH, Brolin R, Sarwer DB, Anderson WA, Dixon J, Guven S. American Association of Clinical Endocrinologists, The Obesity Society, and American Society for Metabolic & Bariatric Surgery medical guidelines for clinical practice for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient. Obesity (Silver Spring) 2009; 17 Suppl 1:S1-70, v. [PMID: 19319140 DOI: 10.1038/oby.2009.28] [Citation(s) in RCA: 199] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
American Association of Clinical Endocrinologists, The Obesity Society, and American Society for Metabolic & Bariatric Surgery Medical Guidelines for Clinical Practice are systematically developed statements to assist health-care professionals in medical decision making for specific clinical conditions. Most of the content herein is based on literature reviews. In areas of uncertainty, professional judgment was applied. These guidelines are a working document that reflects the state of the field at the time of publication. Because rapid changes in this area are expected, periodic revisions are inevitable. We encourage medical professionals to use this information in conjunction with their best clinical judgment. The presented recommendations may not be appropriate in all situations. Any decision by practitioners to apply these guidelines must be made in light of local resources and individual patient circumstances. The American Society for Parenteral & Enteral Nutrition fully endorses sections of these guidelines that address the metabolic and nutritional management of the bariatric surgical patient.
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Mechanick JI, Kushner RF, Sugerman HJ, Gonzalez-Campoy JM, Collazo-Clavell ML, Guven S, Spitz AF, Apovian CM, Livingston EH, Brolin R, Sarwer DB, Anderson WA, Dixon J. American Association of Clinical Endocrinologists, The Obesity Society, and American Society for Metabolic & Bariatric Surgery Medical guidelines for clinical practice for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient. Endocr Pract 2008; 14 Suppl 1:1-83. [PMID: 18723418 DOI: 10.4158/ep.14.s1.1] [Citation(s) in RCA: 144] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Mechanick JI, Kushner RF, Sugerman HJ, Gonzalez-Campoy JM, Collazo-Clavell ML, Guven S, Spitz AF, Apovian CM, Livingston EH, Brolin R, Sarwer DB, Anderson WA, Dixon J. American Association of Clinical Endocrinologists, The Obesity Society, and American Society for Metabolic & Bariatric Surgery Medical Guidelines for Clinical Practice for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient. Surg Obes Relat Dis 2008; 4:S109-84. [PMID: 18848315 DOI: 10.1016/j.soard.2008.08.009] [Citation(s) in RCA: 191] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
American Association of Clinical Endocrinologists, The Obesity Society, and American Society for Metabolic & Bariatric Surgery Medical Guidelines for Clinical Practice are systematically developed statements to assist healthcare professionals in medical decision making for specific clinical conditions. Most of the content herein is based on literature reviews. In areas of uncertainty, professional judgment was applied. These guidelines are a working document that reflects the state of the field at the time of publication. Because rapid changes in this area are expected, periodic revisions are inevitable. We encourage medical professionals to use this information in conjunction with their best clinical judgment. The presented recommendations may not be appropriate in all situations. Any decision by practitioners to apply these guidelines must be made in light of local resources and individual patient circumstances. The American Society for Parenteral & Enteral Nutrition fully endorses sections of these guidelines that address the metabolic and nutritional management of the bariatric surgical patient.
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Izrailtyan I, Clark J, Swaminathan M, Podgoreanu MV, Mackensen B, Davis RD, Mathew JP. Case report: Optimizing intraoperative detection of pulmonary embolism using contrast-enhanced echocardiography. Can J Anaesth 2006; 53:711-5. [PMID: 16803919 DOI: 10.1007/bf03021630] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
PURPOSE Perioperative pulmonary embolism (PE) is associated with significant morbidity and mortality. Intraoperatively, the clinical management of patients with PE can be enhanced by the use of transesophageal echocardiography (TEE) to visualize emboli, assess pulmonary artery (PA) anatomy, and monitor the function of the right ventricle. However, the sensitivity of intraoperative TEE to detect thromboemboli is reported to be below 50%. In this report, we describe the use of contrast-enhanced TEE (CE-TEE) to improve the visualization of PE. CLINICAL FEATURES A 44-yr-old female with chronic thrombo-embolic pulmonary hypertension was scheduled for pulmonary thromboendarterectomy. The precardiopulmonary bypass TEE exam demonstrated signs of PA obstruction and right ventricle dysfunction, but the borders of the thrombus in the right PA were only minimally visualized. Perflutren lipid microspheres, composed of octafluoropropane encapsulated in an outer lipid shell, were injected as a 0.3 mL iv bolus, while visualizing the right PA with harmonic ultrasound imaging. The CE-TEE image clearly visualized a large mobile thrombus along with a distinct pattern consistent with pulmonary flow obstruction. The postcardiopulmonary bypass CE-TEE confirmed thrombus evacuation and absence of PA flow abnormalities. CONCLUSION Contrast-enhanced-TEE may decrease operator dependency and increase the sensitivity necessary to detect central, surgically accessible PE.
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Affiliation(s)
- Igor Izrailtyan
- Department of Anesthesiology, Duke University Medical Center, Durham, NC 27710, USA
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Abstract
To report a non-fatal case of reperfusion pulmonary edema (RPE) after the removal of a hepatocellular carcinoma embolus, which had caused an acute obstruction of the tricuspid valve and pulmonary vasculature during a hepatic lobectomy. Pulmonary embolism caused by hepatocellular carcinoma embolus is extremely rare, and, in the present case, it was associated with unusual clinical features. A 69-year-old ASA II woman with hepatocellular carcinoma was presented for an elective left hepatic lobectomy. During the surgery, the tumor embolus was dislodged from the interior of the lumen of the inferior vena cava (IVC), which then drifted into the tricuspid valve area and pulmonary vasculature. The patient showed the specific signs of acute pulmonary embolism, such as a reduction in end-tidal carbon dioxide, an increase in central venous pressure, and a decrease in arterial pressure. The patient exhibited the symptoms for about 10 minutes. After this period, however, cardiovascular variables became relatively stable, even during a mechanical obstruction due to cross-clamping the pulmonary artery for embolectomy. After several hours of pulmonary embolectomy, the patient experienced an episode of RPE. The ventilatory supports for the treatment of RPE were successful, and the patient recovered without any complications. The patient's case in the present study demonstrates that pulmonary embolism may occur as a result of a hepatocellular carcinoma extending into the IVC during operative management. The anesthesiologist should be careful of the possibilities of RPE after removal of the tumor embolus.
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Affiliation(s)
- Jae-Min Lee
- Department of Anesthesiology, School of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Hae-Jin Lee
- Department of Anesthesiology, School of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Eun-Sung Kim
- Department of Anesthesiology, School of Medicine, The Catholic University of Korea, Seoul, Korea
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Maurtua M, Zhang W, Deogaonkar A, Farag E, Ebrahim Z. Massive pulmonary thromboembolism during elective spine surgery. J Clin Anesth 2005; 17:213-7. [PMID: 15896591 DOI: 10.1016/j.jclinane.2004.06.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2004] [Accepted: 06/09/2004] [Indexed: 11/20/2022]
Abstract
Massive pulmonary thromboembolism (PTE) is a condition that can still be seen in the operating room despite the use of thromboprophylaxis. A high degree of suspicion of this condition is necessary to achieve an early diagnosis and a rapid treatment to improve patient outcome. We report on a 27-year-old patient who sustained a massive PTE while undergoing a second-stage anterior release and posterior fusion of his thoracolumbar spine for idiopathic scoliosis.
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Affiliation(s)
- Marco Maurtua
- Department of General Anesthesiology, The Cleveland Clinic Foundation, Cleveland, OH 44195, USA.
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Affiliation(s)
- John David Prologo
- Department of Radiology, University Hospitals of Cleveland, 11100 Euclid Avenue, Cleveland, OH 44106, USA.
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Massive Pulmonary Embolism during Elective Spine Surgery. J Neurosurg Anesthesiol 2004. [DOI: 10.1097/00008506-200410000-00111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
Pregnancy induces significant physiologic stresses on the pulmonary and cardiovascular systems that may precipitate respiratory compromise. In addition, certain disease states that are unique to the pregnant woman, such as amniotic fluid emboli syndrome, may be associated with respiratory failure. The physiologic changes that affect the pregnant woman are reviewed. Pregnancy-related conditions are discussed as well as how common diseases, such as the acute respiratory distress syndrome, asthma, pneumonia, and AIDS,have to be approached when balancing the needs of the fetus with maternal well-being.
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Affiliation(s)
- Adriana Pereira
- Pulmonary Division, Mount Sinai Medical Center, 4300 Alton Road, Miami Beach, FL 33140, USA
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Affiliation(s)
- Greg Stratmann
- *Department of Anesthesia and Perioperative Care and †Pediatrics, University of California at San Francisco
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Ayoub CM, Zreik TG, Dabbous AS, Baraka AS. Amniotic fluid embolus: can we affect the outcome? Curr Opin Anaesthesiol 2003; 16:257-61. [PMID: 17021468 DOI: 10.1097/00001503-200306000-00003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Amniotic fluid embolism is a rare catastrophe unique to pregnancy. Its mortality rate remains high despite efforts at prompt and aggressive management protocols, highlighting the need to maintain a high index of suspicion. RECENT FINDINGS The intrusion of amniotic fluid into the maternal bloodstream may lead in certain women to a complex series of physiological reactions mimicking those seen in human anaphylaxis or sepsis, negating the purely embolic phenomenon theory as previously understood. The clinical picture is the sudden onset of cardiovascular collapse, cyanosis, haemorrhage or disseminated intravascular coagulopathy, during or soon after delivery. SUMMARY The mainstay of a successful outcome remains the identification of high-risk patients, as well as early clinical diagnosis and management.
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Affiliation(s)
- Chakib M Ayoub
- Department of Anesthesiology, American University of Beirut Medical Center, Beirut, Lebanon.
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Abstract
Obesity is associated with a chronic inflammatory state that predisposes to atherogenesis, thrombogenesis, and carcinogenesis and may increase susceptibility to infections. Critically ill, obese patients have higher mortality. MOF is the best predictor of ICU mortality for obese patients. Pulmonary hypertension and higher BMI are associated with higher surgical risk. Progress in surgical technique and anesthesia has substantially improved the safety of performing operations in severely obese patients.
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Affiliation(s)
- Daniela Levi
- Albert Einstein College of Medicine, Critical Care Services, Montefiore Medical Center, 111 East 210 Street, Bronx, NY 10467, USA.
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