[Removal of femoral interlocking nail-induced pulmonary embolism under spinal anesthesia--a case report]

Most of the lower limb surgeries are done under spinal anesthesia. This 21 year-old male had undergone open reduction with interlocking nail for his right femoral fracture and was scheduled for removal of interlocking nail. Spinal anesthesia was performed and a sensory block up to T8 level was achieved. During removing of the nail, the patient complained of chest pain, dyspnea and headache. Consequently, tachycardia and hypotension were observed. Then he coughed up pink frothy sputum. Ephedrine 5 mg was given to raise his blood pressure. About 3 min later, he recovered from the hypotension. Arterial blood gas analysis showed hypoxemia and hypercapnia. After endotracheal intubation, he was sent to surgical intensive care unit. In surgical intensive care unit, fat globules in urine, anemia and thrombocytopenia were noted. Chest roentgenogram showed patchy pulmonary infiltrates in the left lower lobe. A pulmonary artery catheter was inserted for pulmonary measurement, which read pulmonary artery pressure 45/28 mmHg, wedge pressure 14 mmHg, and cardiac output was 5-34 L/min. Supportive treatment which included steroid therapy, and O2 therapy with positive end-expiratory pressure was initiated under the impression of pulmonary embolism. The course in surgical ICU was uneventful and he left there three days later and was discharged on the fifth hospitalization day.