[Massive intraoperative pulmonary embolism. Diagnosis and control following embolectomy with transesophageal...

Massive intraoperative embolism is a life-threatening condition that may lead to immediate death. Important for the survival of the patient are rapid diagnosis and prompt surgical embolectomy. Case report. Nineteen days after a traffic accident, a 67-year-old patient who had complex ligamentous injuries was operated upon on both knees during general anaesthesia. The operation progressed uneventfully for the first 30 min when the patient's systolic blood pressure became slightly unstable and decreased to 85 mm Hg despite administration of ephedrine and infusion of hetastarch. This was followed 30 min later by an immediate drop to values that were undetectable on an oscilloscope. The pulse oximeter no longer detected a signal at the finger-tip and the end-tidal CO2 decreased to 1 kPa (7.5 mm Hg). To confirm the diagnosis of an acute pulmonary embolism, we performed transoesophageal echocardiography (TEE) and found a large amount of free-floating material in the right atrium, a dilated and hypokinetic right ventricle, and a collapsed left ventricle (Fig. 1 a). Embolectomy was immediately started using the inflow-occlusion technique supported by cardiopulmonary bypass (CPB). All emboli were removed from the right atrium and pulmonary artery (Fig. 1 b). During closure of the sternotomy, heart function was monitored by TEE and we again noted large emboli in the right atrium (Fig. 1 c). To remove these, we reinstated CPB and then placed an inferior vena cava filter. The final TEE control showed free heart chambers with good contractility (Fig. 1 d).(ABSTRACT TRUNCATED AT 250 WORDS)