2024 FSA Podium and Poster Abstracts
P071: EXPEDITIOUS MANAGEMENT OF PERIOPERATIVE ACUTE MASSIVE PULMONARY EMBOLISM
Adriana Grossman, MD, MPH, MHA; Giancarlo Atassi, MD; Jay Grossman, MD; UM/Jackson Memorial Hospital
Introduction: The diagnosis and management of acute massive pulmonary embolism (PE) during the perioperative period presents unique challenges as immediacy of response and quick access to imaging and extracorporeal membrane oxygenation (ECMO) are paramount to survival. Accurate diagnosis using echocardiography and treatment with clot-dissolving therapies must happen synchronously as well.
Methods: The patient is a 59 year-old female with a past medical history of a tummy-tuck procedure in 2022 at a foreign hospital that resulted in a perioperative stroke and ventriculoperitoneal (VP) shunt placement. In 2024, the patient was found to have an intraperitoneal abscess at the site of the VP shunt. The shunt was then externalized for a 14-day hospitalization with intravenous antibiotics. The patient the presented for revision of the VP shunt.
Results: After induction and positioning the patient desaturated to 74% at 100% FiO2 and the ETCO2 markedly decreased. The endotracheal tube was found to be well positioned under fiberoptic guidance. Given the concomitant changes in vitals and ETCO2, a presumptive diagnosis of PE was made. The patient was taken to CT for emergent imaging. Upon arrival to CT the patient became pulseless and ACLS was initiated. The patient received chest compressions and two doses of alteplase (TPA) therapy. On TEE the right atrium and right ventricle were dilated with severe tricuspid regurgitation, all consistent with an acute massive PE. After an hour of ACLS cardiac function began to improve. Cardiac surgery was consulted and felt the patient would benefit from ECMO though initial radiographic evidence of PE was inconclusive. ECMO run was initiated and the patient was transferred to a facility more adept for ECMO management. The patient is still currently in CVICU and remains on ECMO run.
Discussion: There are currently no guidelines for management of acute massive PE in the perioperative setting. TPA use in the immediate period of acute massive PE is currently recommended only though the use of a central line, though in this case it was administered through a peripheral IV. A case series sites the immediate use of the drug as paramount when TEE imaging modalities are available to observe the progress of cardiac function after administration1. Other studies tout the use of intra-vascular sheaths for administration of heparin and TPA over the course of days2. In these instances the patients did not remain intubated and did not require ECMO. The close proximity of a TEE machine, a CT scanner, TPA and the opportunity for E-CPR are plausible sources of this patient’s survival and are worth exploring as considerations for future cases.
References:
- Kim JY, Lee YS, Park HO, Shin IW. Management of perioperative acute massive pulmonary embolism: A case series. Clin Case Rep. 2021 Mar 28;9(5):e04078. doi: 10.1002/ccr3.4078. PMID: 34084497; PMCID: PMC8142415.
- Porres-Aguilar M, Rivera-Lebron BN, Anaya-Ayala JE, León MCG, Mukherjee D. Perioperative Acute Pulmonary Embolism: A Concise Review with Emphasis on Multidisciplinary Approach. Int J Angiol. 2020 Sep;29(3):183-188. doi: 10.1055/s-0040-1709501. Epub 2020 May 14. PMID: 33149540; PMCID: PMC7599112.