Case Report
Copyright ©The Author(s) 2022. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Clin Cases. May 26, 2022; 10(15): 5111-5118
Published online May 26, 2022. doi: 10.12998/wjcc.v10.i15.5111
Anesthetic management for intraoperative acute pulmonary embolism during inferior vena cava tumor thrombus surgery: A case report
Pei-Yu Hsu, En-Bo Wu
Pei-Yu Hsu, Department of Anesthesiology, China Medical University Hospital, China Medical University, Taichung 404, Taiwan
En-Bo Wu, Department of Anesthesiology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 833, Taiwan
Author contributions: Hsu PY collected clinical data, discussed the details, contributed to the draft writing; Wu EB modified the manuscript and was a major contributor in writing the manuscript. Both authors read and approved the final manuscript.
Informed consent statement: Informed written consent was obtained from the patient for publication of this report and any accompanying images.
Conflict-of-interest statement: The authors have no conflicts of interest to declare.
CARE Checklist (2016) statement: The authors have read the CARE Checklist (2016), and the manuscript was prepared and revised according to the CARE Checklist (2016).
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: En-Bo Wu, MD, Attending Doctor, Department of Anesthesiology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, No. 123 Ta-Pei Road, Niao-Song District, Kaohsiung 833, Taiwan. enbofive@gmail.com
Received: January 6, 2022
Peer-review started: January 6, 2022
First decision: February 21, 2022
Revised: March 1, 2022
Accepted: March 27, 2022
Article in press: March 27, 2022
Published online: May 26, 2022
Abstract
BACKGROUND

Acute pulmonary embolism (APE) is a rare and potentially life-threatening condition, even with early detection and prompt management. Intraoperative APE required specific ways for detecting since classic symptoms of APE in the awake patient could not be observed or self-reported by the patient under general anesthesia.

CASE SUMMARY

A 44-year-old man with a history of hepatic cell carcinoma was admitted for radical nephrectomy and tumor thrombectomy due to a newly found kidney tumor with inferior vena cava (IVC) tumor thrombus. APE that occurred during tumor thrombectomy with hypercapnia and desaturation. The capnography combined with the transesophageal echocardiography (TEE) provided a crucial differential diagnosis during the operation. The patient was continuously managed with aggressive intravenous fluid resuscitation and blood transfusion under continuous cardiac output monitoring to maintain hemodynamic stability. He completed the surgery under stable hemodynamics and was extubated after percutaneous mechanical thrombectomy by a certified cardiologist. There were no significant symptoms and signs or obvious discomfort in the patient’s self-report during visits to the general ward.

CONCLUSION

Under general anesthesia for IVC tumor thrombus surgery, a sudden decrease in end-tidal carbon dioxide is the initial indicator of APE, which occurs before hemodynamic changes. When intraoperative APE is suspected, TEE is useful in the diagnosis and monitoring before computer tomography pulmonary angiogram. Timely clinical impression and supportive treatment and intervention should be conducted to obtain a better prognosis.

Keywords: Acute pulmonary embolism, Anesthesia, End-tidal carbon dioxide, Inferior vena cava tumor thrombus, Transesophageal echocardiography, Case report

Core Tip: Intraoperative acute pulmonary embolism (APE) is a potentially life-threatening condition, while early detection with prompt management may help improve prognosis. An acute decrease in end-tidal carbon dioxide is an early sign indicating APE. When intraoperative APE is suspected, transesophageal echocardiography is useful in the diagnosis and monitoring before computer tomography pulmonary angiogram. Besides rapid diagnosis, further management and supportive treatment should also be considered to save the patient’s life.