2024 FSA Podium and Poster Abstracts
P106: BILATERAL PULMONARY EMBOLI AFTER INDUCTION OF ANESTHESIA
Kayla Yoshida, DO; Emily Chung; David McDougal; Shayla McMahon; HCA Florida Kendall Hospital
Introduction: Acute pulmonary emboli are a life-threatening event that can arise intraoperatively and are essential for the anesthesiologist to know how to manage. Perioperative and postoperative pulmonary embolism have an impressive combined incidence rate ranging between 0.7 - 30% in the orthopedic surgery population. This phenomenon is most likely due to the nature of orthopedic surgeries being so near in proximity to the deep venous system of the lower extremity. Thus, the importance of sufficient thromboprophylaxis is highlighted in this study. Patients with many high risk factors for developing DVT’s and PE’s should be given prolonged anticoagulation prophylaxis.
Case Report: This case covers a 75 y.o. female with a history of hypertension, hyperlipidemia, and DM who presented to the ED with painful swelling to her left knee. The patient reported a surgical history of L knee arthoplasty that she had one month ago and reported that she noticed the swelling worsening over the past month. The patient arrived with severe sepsis with tachycardia, fever, leukocytosis (WBC = 14), and elevated lactate level to 6.9. The patient was thus treated with sepsis bundle of 30 cc/kg IV fluids and broad spectrum IV antibiotics (Piperacillin-Tazobactam and Vancomycin). The surgery team was consulted and the patient was scheduled for L Knee I&D in the morning.
Management: The patient went for I&D of left knee and underwent standard induction and was easily intubated. Upon induction, the patient acutely desaturated to the 80’s and ETCO2 dropped. FiO2 was increased to 100%, peak pressures were found to be within acceptable range and the patient was hemodynamically stable. We suspected PE and canceled the case. The patient was taken intubated to PACU for ICU admission and suspected pulmonary embolism work-up.
She was stabilized and taken to PACU where she later developed AFib with RVR and hypotension. The patient was cardioverted to NSR and started on a norepinephrine drip for BP assistance. A bedside TTE confirmed suspicions for pulmonary embolism with a visible “D-sign” and the pt was taken for emergent CTA chest.
The evidence from the CTA chest confirmed bilateral subsegmental acute PE. The pt was then swiftly taken for a successful bilateral mechanical pulmonary thrombectomy. The patient was transferred to the ICU for post-op monitoring and eventual weaning from the ventilator.
Discussion & Conclusion: Acute PE is associated with a high risk of perioperative mortality at 12.5%, thus, prompt management is of utmost importance by the anesthesiologist and the rest of the healthcare team. When an acute PE is suspected intraoperatively, the anesthesiologist should increase FiO2 to 100% if it is not already and hemodynamics should be supported with vasopressors to maintain MAP and perfusion to end organs in the circumstance of obstruction. Some other signs of PE can be S1Q3T3 pattern seen on EKG, tachycardia, elevated JVP, and wheezing. Another helpful test as completed in this case is a bedside TTE, looking for RV strain and “D-sign”. Confirmatory tests include the gold-standard CTA-chest and V/Q scans.