1. Presented by: Dr.Hasmukh Patel 1 Dr.Rajesh Thosani 1 Dr.Hemang Gandhi 1 Dr.Chirag Doshi 2 Dr.Naman Shastri 1 U.N.Mehta Institute of Cardiology and Research Center 1.Cardiac Anesthesia 2.Cardio Vascular and Thoracic Surgery Acute pulmonary embolism – a case report

2. INTRODUCTION Relatively common cardiovascular emergency. Occluding the pulmonary arterial bed it may lead to acute life- threatening but potentially reversible right ventricular failure. Difficult to diagnosis because of non-specific clinical presentation. Early diagnosis is fundamental, since immediate treatment is highly effective. Acute case fatality rate is 31% presenting with hemodynamic instability. 1

3. MATERIAL & METHOD A 22 years old male patient, presented with progressively increasing dyspnea since last 4-5 days. On examination patient had RR of 32/min with decrease air entry on right side. Chest x-ray : right side hyperlucency ECG : right heart strained pattern 2D echocardiography: dilated RA & RV, large thrombus in proximal RPA, severe TR with moderate to severe PAH, RVSP 90 mmhg, mild pericardial effusion. Doppler ultrasound : superficial vein thrombosis of right great saphenous vein with no deep vein involvement.

4. Main pulmonary trunk, right & left pulmonary arteries dilated. CT Pulmonary Angiography:

5. Right pulmonary artery complete occlusion up to segmental and subsegmental branches of all lobes. Partial thrombus in left upper lobe pulmonary artery. Left lower lobe pulmonary arterial branch chronic complete occlusion. MPA = 32.3 mm, RPA = 21.4 mm, LPA = 21.7 mm Wedge shape opacity in right lower lobe.

6. Patient was taken to operating room, 18g iv cannula inserted in peripheral vein & radial artery cannulation performed. Induction was done as per institution protocol & right IJV secured with triple lumen catheter. After median sternotomy patient was heparinized and CPB established through aorta and RA cannulation. Systemic cooing to 18ºC achieved for DHCA. Under CPB right sided pulmonary embolectomy was performed. Patient came off from CPB uneventfully & shifted to ICU with support of milrinone 0.5 mcg/kg/min Patient weaned and extubated after 8 hrs of ventilation. Infusion milrinone continued till 48 hrs. Post operative echocardiography: Moderate TR, Mild RV dysfunction, RVSP 48 mmhg, Normal LV function.

7. DISCUSSION The best surgical candidates are the ones with an accessible clot in the main PA or proximal right and left PA. In the presence of PE and RV dysfunction, induction methods should emphasize the importance of avoiding any situations that would lead to hypoxia, hypercarbia, or hypotension. Intraoperative monitoring should include an arterial catheter, ECG, pulse oximeter, capnograph, and CVP catheter. Large-bore intravenous catheters are necessary to ensure good venous access in case of massive pulmonary hemorrhage. 2 In cases of a massive PE in which 50% of the pulmonary blood flow is obstructed, a fixed CO makes them extremely susceptible to hemodynamic collapse. Some surgeons prefer cannulation of the femoral vessels before induction in preparation for immediate CPB in the setting of hemodynamic compromise.

8. It is also extremely important to implement measures to decrease PVR, such as treating acidosis and maintaining hypocapnia, without excessively increasing airway pressure. Frequently, an inotrope is required before or during induction to maintain perfusion pressure to the right heart. Dobutamine or milrinone, when titrated to maintain a moderate blood pressure, improve ventricular performance, whereas PVR does not increase significantly. 3 Immediate availability of TEE and interpretation by a qualified practitioner served to assist in the anesthetic management of volume, inotropes, and vasopressors as well as to exclude a PFO, atrial septal defect, or any visible thrombus in the right atrium, right ventricle, or main PA. Open pulmonary embolectomy before RV ischemia and cardiac arrest ensue is imperative for the favorable outcome of patients with massive acute PE. 4

9. CONCLUSION A pulmonary embolism is a rare occurrence so majority of anesthetist cannot come across for its management routinely. These kind of emergency cases require skill and expertise in special care for invasive cannulation, selection of inotropes and use of TEE for assessment of heart in intraoperative period. References: 1.Kasper W, Konstantinides S, Geibel A, et al:Management strategies and determinants of outcome in acute major pulmonary embolism: results of a multicenter registry.J Am Coll Cardiol 30:1165,1997. 2.Shimokawa S, Uehara K, Toyohira H, et al: Massive endobronchial hemorrhage after pulmonary embolectomy, Ann Thorac Surg 61:1241, 1996. 3.Layish DT, Tapson VF: Pharmacologic hemodynamic support in massive pulmonary embolism,Chest111:218,1997 4.Dauphine C, Omari B: Pulmonary embolectomy for acute massive pulmonary embolism, Ann Thorac Surg79:1240,2005