Ognjen Visnjevac
1, Leili Pourafkari
2, Nader D. Nader
1*1 Departments of Anesthesiology, Critical Care, and Surgery, University at Buffalo, Buffalo, New York, USA
2 Cardiovascular Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
*Corresponding Author: Departments of Anesthesiology, Critical Care, and Surgery, University at Buffalo, Buffalo, New York, USA, Email:
nnader@buffalo.edu
Abstract
Purpose:Massive
thromboembolic intraoperative pulmonary embolism (IOPE)is rare butcarries a
great degree of morbidity and mortality. This is the first study to formally
assess the utility of various tools for the diagnosis of these events and the
impact of each tool on mortality.
Methods:Due
to both the infrequent occurrence of these events and the high mortality of
massive IOPE, it was cost-prohibitive to prospectively randomize patient
patients to study commonly used diagnostic tools. Hence,a descriptive review of
all reported cases in the literature was performed. This review yielded146
cases for past 4 decades. Following a careful review of these cases, the
alerting monitor for the occurrence of IOPE was recorded. Furthermore, we
recorded the confirming diagnostic tool and the outcome of these patients. We
compared4 monitoring tools: (1) end-tidal carbon dioxide; (2) central catheter
pressures; (3) echocardiography; and (4) standard monitoring of vital signs.
Results:Pre-event
use of transesophageal echocardiographyhad no survival benefit. End-tidal
carbon dioxide changes as an alerting tool were associated with improved
survival compared to changes in vital signs (P<0.0001). Signs of right heart
strain were associated with greater mortality, but direct thrombus
visualization was not.
Conclusions:Echocardiography
appears to be useful for diagnosis of massive IOPE. Compared with hemodynamic
collapse, end-tidal carbon dioxide decline as the presenting sign of massive
IOPE may be associated with a better prognosis because it may represent earlier
detection of IOPE and allow for more time to intervene.