2024 FSA Podium and Poster Abstracts
P056: PULMONARY EMBOLISM, A DIFFICULT DIAGNOSIS
Luke A Sala, MD, MBA, MS; Philip Smith, MD; UMiami/Jackson Memorial Hospital
Introduction/background: Pulmonary embolism, a dangerous yet relatively common complication of surgery especially in the setting of trauma anesthesiology. However, often the nature of trauma patients includes multiple injuries and, in this context, can be more difficult to develop resolute diagnosis.
Case: A 20-year-old-male with no significant past medical history presented to Ryder Trauma Center after gunshot wounds to the left chest, abdomen and right leg. On initial presentation the patient was hemodynamically stable and was sent to CT. Imaging was concerning for left-sided pneumothorax, left lower lobe pulmonary contusions, and injuries to left kidney, spleen and diaphragm prompting chest tube placement and urgent surgery. The patient underwent left nephrectomy, diaphragm repair, and closure of gastrostomy without anesthetic complication. Postoperatively, over the next 36 hours, the patient was weaned and extubated in the ICU to 4 liters nasal cannula. Interval CXR showed continued left apical pneumothorax with worsening opacification of left lung and layering pleural effusion versus hemothorax. Of note, in the postoperative period there was continuous concern for bleeding. Hgb decreased from 10.2 to 7.5 with 3 units of PRBC transfusion, and anticoagulation was stopped. There were infectious concerns with white count uptrending to 14.3 and intermittent fevers. The patient was planned to return to the OR 48 hours after surgery for right lower extremity IM nail placement. At this time patient had been extubated 12 hours and off anticoagulation for 24 hours.
Methods: Intra-operatively patient was intubated without complication, however, within the first 20 minutes patient began to desaturate. This was thought to be secondary to known contusions, effusions, PTX and recruitment maneuvers were performed. The patient continued to saturate in low 90’s and tidal volumes were decreasing with new concern for bronchospasm versus mainstream intubation. Bilateral breath sounds were confirmed with auscultation and the patient was promptly treated with albuterol without interval improvement. Saturation continued in the low 90’s, concern for mucus plug prompted bronchoscopy without significant findings. The patient became hypotensive requiring frequent phenylephrine boluses and surgical team was made aware of patient instability. An ABG was drawn and before results were available ETCO2 decreased from mid 30’s to 20. The ABG was significant for PaCO2 45 and PaO2 of 97.
Results: There was significant concern for pulmonary embolus, and the case was canceled. As volatile anesthetic decreased, oxygen saturation improved and hypotension resolved. The patient underwent CTA chest which revealed multiple pulmonary emboli in right upper (filling defect in posterior segments) and lower lobes (posterior basilar segments), interval development of consolidation in right upper lobe, trace left apical PTX, and bilateral pleural accumulations.
Discussion/conclusion: Otherwise healthy patients may be more easily diagnosed, however, it can be very difficult to elucidate pulmonary embolus when it is a diagnosis of exclusion. In this case, the correlation of ventilation to perfusion was an ominous and clinically significant sign which prompted further investigation.