Management of pulmonary embolism in postoperative patients

Abstract

Dear Editor: With this case we raise an important issue; the need for institution specific guidelines for the management of massive pulmonary embolism in post-operative surgical patients. Case report A 67 year old lady with hypertension and had laparoscopic cholecystectomy for carcinoma of the gallbladder three years prior to this presentation was admitted to hospital for one week after an emergency laparotomy for sub-acute intestinal obstruction. Three days after discharge she represented to the emergency department with burst abdomen and severe sepsis. Laparotomy and abdominal washout were performed urgently. The patient was extubated at the end of the procedure and transferred to the post-anesthesia care unit where she initially made a good recovery. However, the next day she suddenly developed hypoxia, tachypnea, tachycardia, hypotension and confusion. Her ECG showed sinus tachycardia with deep S wave in lead 1 and Q wave and T wave inversion in lead 3. A plain chest radiograph was unremarkable and echocardiography revealed right heart strain (right atrium moderately dilated, right ventricle mildly dilated, moderate tricuspid regurgitation, moderate pulmonary arterial hypertension). Although the patient was too unstable to transfer to the computed tomography suite for pulmonary angiography the cardiologist on call, pulmonologist on call, her anesthetist and surgeon all agreed that the probability of massive pulmonary embolism (PE) was high. Treatment dose of low molecular weight heparin was given whilst systemic thrombolysis, intra-arterial thrombolysis and embolectomy were considered. After nearly two hours of multi-disciplinary debate on the instability of the patient, differential diagnosis, paucity of data and risk of haemorrhage only a tacit consensus in favor of thrombolysis was achieved. Unfortunately, no definitive decision was made and so the patient had a pulseless electrical activity cardiac arrest whilst the deliberation continued. Thrombolysis was not administered; resuscitation was attempted but was sadly unsuccessful. Discussion Several meta-analyses report that thrombolysis reduces mortality in patients with massive PE. [1Marti C John G Konstantinides S Combescure C Sanchez O Lankeit M Meyer G Perrier A Systemic thrombolytic therapy for acute pulmonary embolism: a systematic review and meta-analysis.Eur Heart J. 2015; 36: 605-614Crossref PubMed Scopus (287) Google Scholar,2Neely RC Byrne JG Gosev I Cohn LH Javed Q Rawn JD Goldhaber SZ Piazza G Aranki SF Shekar PS Leacche M Surgical Embolectomy for Acute Massive and Submassive Pulmonary Embolism in a Series of 115 Patients.AnnThorac Surg. 2015; 100 (discussion 1251-2.): 1245-1251Abstract Full Text Full Text PDF Scopus (83) Google Scholar] However, there is a higher risk of major bleeding in those over 65 years old and all trials to date have specified standard exclusion criteria for thrombolytic therapy, including recent major surgery or trauma. Hence, these data cannot be applied to post-operative surgical patients. The current Advanced Cardiac Life Support (ACLS) guidelines do not specifically discuss post-operative patients. Furthermore, although case reports have described good outcomes from thrombolysis in post-operative patients, [3Hartmannsgruber MW Trent FL Stolzfus DP Thrombolytic therapy for treatment of pulmonary embolism in the postoperative period: case report and review of the literature.J Clin Anesth. 1996; 8: 669-674Abstract Full Text PDF PubMed Scopus (5) Google Scholar] more recent series have focused on the role of surgical embolectomy in this cohort. [2Neely RC Byrne JG Gosev I Cohn LH Javed Q Rawn JD Goldhaber SZ Piazza G Aranki SF Shekar PS Leacche M Surgical Embolectomy for Acute Massive and Submassive Pulmonary Embolism in a Series of 115 Patients.AnnThorac Surg. 2015; 100 (discussion 1251-2.): 1245-1251Abstract Full Text Full Text PDF Scopus (83) Google Scholar] Randomized trial data are urgently required to guide the decision making in this Catch-22 situation. However, in the interim we are developing a pragmatic protocol for our institution to prevent another prolonged multidisciplinary deliberation as a patient deteriorates. We advise all institutions that manage post-operative patients to do the same. These protocols will clearly depend on the availability of therapeutic interventions and will therefore vary between institutions. The authors have confirmed that appropriate consent was given for publication of this case report. Conflict of Interest: