ISSN:
1432-055X
Keywords:
Schlüsselwörter: Lungenembolie – Transösophageale Echokardiographie – Intraoperative Komplikationen
;
Key words: Pulmonary embolism – Transoesophageal echocardiography – Intraoperative complications
Source:
Springer Online Journal Archives 1860-2000
Topics:
Medicine
Description / Table of Contents:
Abstract. Massive intraoperative embolism is a life-threatening condition that may lead to immediate death. Important for the survival of the patient are rapid diagnosis and prompt surgical embolectomy. Case report. Nineteen days after a traffic accident, a 67-year-old patient who had complex ligamentous injuries was operated upon on both knees during general anaesthesia. The operation progressed uneventfully for the first 30 min when the patient's systolic blood pressure became slightly unstable and decreased to 85 mm Hg despite administration of ephedrine and infusion of hetastarch. This was followed 30 min later by an immediate drop to values that were undectable on an oscilloscope. The pulse oximeter no longer detected a signal at the finger-tip and the end-tidal CO2 decreased to 1 kPa (7.5 mm Hg). To confirm the diagnosis of an acute pulmonary embolism, we performed transoesophageal echocardiography (TEE) and found a large amount of free-floating material in the right atrium, a dilated and hypokinetic right ventricle, and a collapsed left ventricle (Fig. 1 a). Embolectomy was immediately started using the inflow-occlusion technique supported by cardiopulmonary bypass (CPB). All emboli were removed from the right atrium and pulmonary artery (Fig. 1 b). During closure of the sternotomy, heart function was monitored by TEE and we again noted large emboli in the right atrium (Fig. 1 c). To remove these, we reinstated CPB and then placed an inferior vena cava filter. The final TEE control showed free heart chambers with good contractility (Fig. 1 d). The postoperative course of the patient was without complications, and he left the hospital 41 days after the operation without sequelae from the massive pulmonary embolism. Conclusion. Intraoperative diagnosis of acute pulmonary embolism with shock is difficult. Clinical signs are unspecific and are rarely present during general anaesthesia. ECG changes may occur only later. As a result of the persistent shock, the pulse oximeter no longer works properly and the decrease in end-tidal CO2 may be explained by other reasons such as low cardiac output from a myocardial infarction. In this situation, TEE is a very useful method for quickly confirming the diagnosis of massive pulmonary embolism. In addition, we have shown that TEE is effective in detecting new emboli after an embolectomy. We conclude that TEE is a life-saving diagnostic tool that is useful for confirming acute pulmonary embolism and controlling the efficacy of embolectomy.
Notes:
Zusammenfassung. Massive pulmonale Thromboembolien mit Kreislaufzusammenbruch führen meist unmittelbar zum Tod des Patienten. Entscheidend für das Überleben sind die schnelle Diagnose und die unverzügliche, operative Embolektomie. Wir berichten über einen 67jährigen Patienten, der 19 Tage nach einem Unfall an beiden Kniegelenken operiert wurde. Intraoperativ kam es zu einem akuten Kreislaufversagen. Durch transösophageale Echokardiographie (TEE) konnte eine Thromboembolie in den rechten Vorhof und in die Arteria pulmonalis bestätigt werden. Sofort wurde eine operative Embolektomie durchgeführt. Die Kontrolle der Herzfunktion mittels TEE während des Verschlusses der Sternumlängsspaltung zeigte ein erneutes Einschwemmen von Thromben in den rechten Vorhof, so daß eine zweite Embolektomie am extrakorporalen Kreislauf nötig wurde. Anschließend erfolgte die Implantation eines Kavafilters. Der Patient überlebte die Eingriffe ohne Folgeschäden. Unser Fall demonstriert eindrücklich den Wert der TEE nicht nur für die Diagnose intraoperativer Lungenembolien, sondern auch für die Erfolgskontrolle nach operativer Embolektomie.
Type of Medium:
Electronic Resource
URL:
http://dx.doi.org/10.1007/s001010050072
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