Pulmonary Embolism
Last modified: 11 August 2022, 12:29:33 PM AEST
- Venous = DVT
- Cement embolism
- embolization of polymethyl methacrylate (PMMA) into lungs
- PMMA is rapidly setting acrylic cement often used in vertebroplasty / joint surgery
- suspicion if rise in ETCO2 > 2 mmHg during cementing
- Air = Venous Air Embolism
Complications1 / 5
- B = Respiratory
- Acute life-threatening hypoxia
- C = Cardiovascular
- RV failure
- Cardiogenic shock
- PEA arrest
Investigations2 / 5
- ECG
- Sinus tachycardia = most common finding
- S1Q3T3 = pattern of cor pulmonale
- "classic" finding = neither sensitive nor specific for PE
- TTE
- RV strain, ⬆RV pressures
- IVS is flat, not circular, creating a LV that is D-shaped
Management3 / 5
- Haemodynamic goals
- support RV
- PL = adequate filling
- INO = support contractility
- AL = minimise PVR
- high risk cardiovascular collapse with initiation of PPV (⬆PVR, RVF)
- support RV
- Manage clot burden
- Start ACT immediately
- Consider IVC filter if ACT CIN
- Life-saving manoeuvres for HDI
- C = Inotropes
- C = Pulmonary vasoD
- C = Thrombolysis
- indications
- Shock = SBP 90, ⬇SBP 40 from baseline
- Cardiac arrest
- Severe hypoxia
- RV failure
- Patent foramen ovale
- tPA 100 mg IV over 2 hours
- indications
- C = Thrombectomy
- Catheter embolectomy
- Surgical embolectomy
- C = ECMO
- if all else fails
- Haemodynamic instability = similar to Mx PHTN
- PL = optimise, caution RVF
- GDT = CVP, PAC, TOE
- AL
- systemic = maintain RV perfusion
- Pulm A vasoD = NO, epoprostenol
- INO = support RV
- inotropes = dobutamine, Ad
- inodilators = milrinone
- PL = optimise, caution RVF
Anaesthetic considerations4 / 5
- Pre-op
- Intra-op
- Induction
- Avoid intubation and PPV
- C = High risk CV collapse
- pre-induction IAL / CVC if possible
- B = Avoid hypoxia / hypercarbia
- avoid high intrathoracic pressures
- D = titrated induction
- Post-op