Management of intra-operative acute pulmonary embolism during general anesthesia: a case report

Acute pulmonary embolism (APE) can be life-threatening. Early detection is even more difficult for patients under general anesthesia as common symptoms are not available and the pathophysiological course of intra-operative APE is influenced by procedures of surgery and anesthesia, which makes patients under general anesthesia a distinctive group.

We report a case of APE during orthopedic surgery under general anesthesia. A 64-year-old female with atrial fibrillation and surgical history of varicosity underwent total right hip replacement surgery under general anesthesia. No arterial or deep vein thrombosis (DVT) was found prior to the surgery, but APE still occurred intraoperatively. The sudden decrease in P_ETCO₂ and increase in PaCO₂ combined other clues raised the suspect of APE, which is further evidenced by transesophageal echocardiogram (TEE). Multidisciplinary consultation was started immediately. After discussion with the consultation team and communication with patient's family members, anticoagulation therapy was started and IVC filter was placed to prevent PE recurrence. The patient went through the operation and discharged uneventfully 30 days later.

Pulmonary embolism is a rare and potentially high-risk perioperative situation, with a difficult diagnosis when occurs under anesthesia. The separation phenomenon of decrease in P_ETCO₂ and increase in PaCO₂ might be a useful and suggestive sign, enabling prompt management and therefore improving the prognosis.