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General Articles: Case Report

Massive Pulmonary Embolism After Application of an Esmarch Bandage

Lu, Chen-Wei MD*,; Chen, Yi-Sharng MD†,; Wang, Ming-Jiuh MD, PhD

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doi: 10.1213/01.ANE.0000104583.77388.02
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Exsanguination with the Esmarch bandage of the lower limb is often used in orthopedic procedures to achieve a bloodless operative field and to reduce operative time. However, serious complications, including pulmonary embolisms, which are fatal in most patients, may develop when the bandage is applied to the lower limb (1–7). We describe the successful resuscitation of a patient who developed pulmonary embolism after the application of an Esmarch bandage, necessitating emergent pulmonary embolectomy and postoperative extracorporeal membrane oxygenation (ECMO).

Case Report

A 71-yr-old man who had received bilateral total knee arthroplasty due to osteoarthritis 8 yr ago experienced a left femoral periprosthetic supracondylar comminuted fracture. He was scheduled for open reduction and internal fixation of the fracture after 3 days of traction. Laboratory and plain radiography of the chest and head did not reveal any other abnormalities.

Spinal anesthesia was performed with 10 mg of 0.5% hyperbaric bupivacaine, resulting in an upper anesthetic level just above the umbilicus. An Esmarch bandage was used to exsanguinate the lower limb, and the tourniquet was applied over the upper thigh region. Five minutes after application of the Esmarch bandage, the patient complained of chest tightness, shortness of breath, and palpitation, and then he lost consciousness. Arterial blood pressure decreased from 136/80 to 60/30 mm Hg, the peripheral oxygen saturation decreased from 98% to 79%, heart rate decreased from 90 to <50 bpm, and end-tidal carbon dioxide partial pressure decreased to 18 mm Hg within 1 min. Endotracheal intubation was performed immediately, and atropine, epinephrine, and dopamine were given through the right internal jugular central venous line, which was introduced immediately after the event. Emergent transesophageal echocardiography (TEE) during resuscitation revealed a severely distended right atrium (RA) and right ventricle (RV), with a large embolus in the RA (Fig. 1). A large embolus was trapped in the foramen ovale, which seemed to be opened because of the greatly increased central venous pressure (35 mm Hg) (Fig. 2). After the TEE diagnosis of massive pulmonary embolism, the cardiac surgeons performed a median sternotomy and placed the patient on cardiopulmonary bypass (CPB) when he was resuscitated. Both ventricles and pulmonary arteries were opened, and many blood clots were removed from the RA, the atrial septum, and the left and right pulmonary artery. In the meantime, the orthopedic surgeon finished the internal fixation procedures for the femoral fracture.

Figure 1.
Figure 1.:
Transesophageal echocardiography of the right atrium and the left atrium. A large embolus (big arrow) was found between the interatrial septum (small arrow) and the superior vena cava. The interatrial septum was bulged toward the left atrium because of increased right atrial pressure. LA = left atrium; RA = right atrium; SVC = superior vena cava.
Figure 2.
Figure 2.:
Transesophageal echocardiography of the right and left atrium. A large embolus (arrows) was entrapped in the opened foramen ovale. Ao = aorta; LA = left atrium; RA = right atrium.

After completion of the embolectomy, the patient could not be weaned from CPB and the sternum could not be approximated because of a severely distended RV and low cardiac output. The CPB was converted to ECMO with the cannulae in the RA and the aorta. The sternum was approximated 3 days after the operation, and the cannulae were replaced into the femoral vessels. The ECMO was used for a further 7 days in the postoperative period. During the 10 days of ECMO use, inotropic drugs including epinephrine, dobutamine, and milrinone were used to treat the RV failure and decrease the pulmonary vascular resistance. Heparin was given at approximately 10 U/h during the use of ECMO to keep the activated coagulation time between 160 and 180 s.

Postoperative ultrasonography revealed thrombi in both the superficial femoral and the right iliac veins. The patient refused placement of an inferior vena cava filter and was discharged 45 days after the operation. The patient was generally well 6 mo after the operation.

Discussion

The Esmarch bandage is often used in many orthopedic procedures to provide a bloodless operative field and to facilitate the operation. However, several complications, including nerve and skin injury (8,9), problems of sterility, and pulmonary embolism, have been reported. Massive pulmonary embolisms after the application of an Esmarch bandage have been reported since 1963 in 10 patients who underwent lower limb orthopedic procedures (1–7,10), and only 2 patients survived. The immediate diagnosis, the rapid institution of CPB to support the failing RV, and the removal of the emboli occluding the pulmonary artery were the most important factors for successful resuscitation. TEE is of great value in a setting of sudden cardiovascular collapse in noncardiac surgical patients. The immediate diagnosis of pulmonary embolism by TEE in our patient hastened the process of decision making, and it took <30 minutes to place the patient on CPB and regain hemodynamic stability after the onset of hypotension and bradycardia in our patient.

This is the first patient to be rescued with emergent pulmonary embolectomy and ECMO who survived an intraoperative massive pulmonary embolism after the application of an Esmarch bandage. We have successfully used ECMO to support the cardiopulmonary system in patients with postcardiotomy cardiogenic shock (11) and in patients undergoing prolonged cardiopulmonary resuscitation (12). In this patient, ECMO was very helpful in supporting the failing RV and improving oxygenation after pulmonary embolectomy. Easy access to the femoral veins, lack of interference with cardiopulmonary resuscitation, portability, and faster installation than conventional CPB make ECMO an attractive alternative in the management of sudden cardiovascular collapse when cardiac surgeons are not immediately available.

The development of deep vein thrombosis during the period of immobilization and detachment of venous thrombi caused by the mechanical stress initiated by the application of an Esmarch bandage were thought to be the mechanism of this near-fatal complication. Preoperative anticoagulation and diagnostic workup should be performed to prevent the development of and exclude the possibility of venous thrombosis in patients with trauma of the lower extremities and delayed surgery. The preoperative diagnostic methods for deep vein thrombosis include compression ultrasonography and venography (13); however, these tests are expensive and not ideal for patients with lower extremity trauma. Recently, a negative quantitative latex d-dimer assay was suggested to exclude the need for further diagnostic workup in patients with a moderate to high risk of deep vein thrombosis (14).

In conclusion, we recommend that TEE be used immediately during unexpected intraoperative cardiovascular collapse and suggest that ECMO is helpful in the treatment of massive pulmonary embolism and acute RV failure.

References

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