A massive pulmonary embolism (PE) is a major catastrophe during the intra-operative period [1,2]. In a rare case of massive PE, it has been attributed to the patient's position on the orthopaedic fracture table .
A 46-year-old obese female, was injured when the motorbike that she was driving collided with a car. On admission, her blood pressure was 55/33 mmHg, with a heart rate of 140 beats per minute. She sustained multiple fractures (pelvis, distal third of the right tibia, proximal third of the left femur). The patient's history and pre-operative examination revealed no pre-existing pathology. Following fluid resuscitation, external fixation was applied to her femur and she was admitted to the intensive care unit for haemodynamic monitoring. She was thought to be haemodynamically stable and was transferred to the orthopaedic service. During her hospital stay, the patient received prophylaxis for thromboembolism. Her medications included enoxaparin 4000 UI given subcutaneously 24-hourly.
On the eighth day after the injury she was scheduled for osteosynthesis of the fractures. The patient received a standard general anaesthesia. Anaesthesia was completed uneventfully. No depolarizing relaxant was used. Shortly after placing the patient on the orthopaedic fracture table, she collapsed abruptly and became bradycardic, hypotensive and hypoxic. Resuscitation was attempted for 20 min without success. Post-morten examination revealed a large embolus in the pulmonary trunk and extending into both main pulmonary arteries.
The occurrence of thromboembolism is a consequence of a post-traumatic coagulation-dependent imbalance during the healing process. A pulmonary embolism occurs more frequently after certain procedures, i.e. patients undergoing major orthopaedic surgery on the lowers limbs, patients with a recent history of thrombophlebitis, or those older than 40 years of age for extensive pelvic or abdominal surgery for malignant disease. Risk factors include advanced age, obesity, neoplasia, congestive heart failure, pregnancy, acute myocardial infarction, oral contraceptives or immobilization .
Our patient had four risk factors: multiple trauma, immobilization, major orthopaedic surgery on the lowers limbs and obesity. Leg manipulation and changes in position could induce the PE. Pre-operative screening using non-invasive diagnostic procedures, such as Doppler ultrasound examination, should be performed. Placement of an inferior vena cava filter (transvenous placement of filters through the femoral or jugular veins using local anaesthesia) might be considered.
In conclusion, we suggest that early assessment and treatment of the deep venous system must be made before manipulation of a patient at risk from PE in the peroperative period.
J. A. TORTOSA
Department of Anaesthesia, 'Virgen de la Arrixaca' University Hospital. Murcia, Spain
1 Stecker MS, Ries MD. Fatal pulmonary embolism during manipulation after total knee arthroplasty. J Bone Joint Surg
2 McHale SP, Tilak DV, Robinson PN. Fatal pulmonary embolism following spinal anaesthesia for caesarean section. Anaesthesia
3 Whitby ME, Hellings MJ. Massive intraoperative pulmonary thromboembolism treated by pulmonary embolectomy. Anaesth Intens Care
4 Dehring DJ, Arens JF. Pulmonary thromboembolism. Disease recognition and patient management. Anesthesiology