Perioperative pulmonary tumor embolus: a case report

A 64-year-old white female underwent an elective exploratory laparotomy, right radical nephrectomy, and excision of a vena cava tumor for renal cell carcinoma. Preoperatively, the patient was diagnosed with a right kidney mass that was invading the right renal artery and vena cava. The patient had received a general endotracheal anesthetic consisting of O2, N2O, forane, fentanyl, pentothal, vecuronium, and hydromorphone. The right nephrectomy was completed by the urologist without incident. Following the nephrectomy, the right renal artery and vein were dissected, and the vena cava was exposed. When a temporary clamp was placed on the vena cava, there was a sudden onset of tachycardia, right bundle branch block with (transient) inversion of the QRS complex, hypotension, decreased end-tidal CO2 and decreased O2 saturation, and increased pulmonary inspiratory pressures that did not resolve when the clamp was removed. The diagnosis of tumor embolus was made and the incision was closed. As arrangements were made to transfer the patient to a nearby hospital with facilities to perform cardiopulmonary bypass and pulmonary embolectomy, the patient was supported with 100% oxygen, intermittent boluses of epinephrine, sodium bicarbonate, and titrated inotropic infusions (dopamine, dobutamine, and epinephrine). Successful embolectomy was accomplished. The patient was discharged on postoperative day 9 in good condition.