Perioperative Pulmonary Embolism Research Articles

Pitfalls in the Diagnosis of Peri-Operative Acute Pulmonary Embolism: A Case Report

An 80 years-old man with hypertension, atrial fibrillation, and coronary artery occlusion disease presented for an elective right femur bipolar hip arthroplasty under general anesthesia. Preoperative transthoracic echocardiography (TTE) showed only preexisting regional wall motion abnormality. During the reversal of muscular relaxation following surgery, there was a sudden decrease in blood pressure associated with rapid ventricular response, which was successfully treated by cardioversion. No decrease in end-tidal carbon dioxide level was observed during the hypotensive episode. However, despite fluid and blood resuscitation and vasopressor treatment, there was a repeated hemodynamic collapse postoperatively. A portable TTE showed dilated right atrium and right ventricle (RV), D-shaped left ventricle, and septal wall motion abnormalities consistent with RV pressure overload (McConnell’s sign). Computed tomography pulmonary angiography revealed multifocal PE (pulmonary embolism). Anticoagulation therapy was continued to avoid PE recurrence. The patient discharged uneventfully 30 days later. Perioperative PE is a rare and perhaps dangerous circumstance that can be challenging to diagnose when it happens under anesthesia. The likelihood of PE should always be suspected at the time of perioperative hemodynamic collapse.

Prevention and treatment of pulmonary embolism after resection of head and neck cancer and research progress in targeted therapy of thrombus

Head and neck cancer is one of the most common malignant tumors, and its primary treatment methods are mainly surgical treatment combined with radiotherapy and chemotherapy. Perioperative pulmonary embolism is a fatal complication that may occur in patients after surgery. At the same time, there is few relevant studies about the postoperative pulmonary embolism in head and neck cancer, and Head and neck surgeons may not attach enough importance to it due to its low incidence. Therefore, a correct understanding of essential knowledge for pulmonary embolism control plays a vital role. This article reviews the diagnosis and development of postoperative pulmonary embolism's as well as diagnosis and treatment and the targeted therapy of thrombus, aiming to increase awareness and provide new ideas.

Incorporating harms into the weighting of the revised Agency for Healthcare Research and Quality Patient Safety for Selected Indicators Composite (Patient Safety Indicator 90).

To reweight the Agency for Healthcare Research and Quality Patient Safety for Selected Indicators Composite (Patient Safety Indicator [PSI] 90) from weights based solely on the frequency of component PSIs to those that incorporate excess harm reflecting patients' preferences for outcome-related health states. National administrative and claims data involving hospitalizations in nonfederal, nonrehabilitation, acute care hospitals. We estimated the average excess aggregate harm associated with the occurrence of each component PSI using a cohort sample for each indicator based on denominator-eligible records. We used propensity scores to account for potential confounding in the risk models for each PSI and weighted observations to estimate the "average treatment effect in the treated" for those with the PSI event. We fit separate regression models for each harm outcome. Final PSI weights reflected both the disutilities and the frequencies of the harms. We estimated PSI frequencies from the 2012 Healthcare Cost and Utilization Project State Inpatient Databases with present on admission data and excess harms using 2012-2013 Centers for Medicare & Medicaid Services Medicare Fee-for-Service data. Including harms in the weighting scheme changed individual component weights from the original frequency-based weighting. In the reweighted composite, PSIs 11 ("Postoperative Respiratory Failure"), 13 ("Postoperative Sepsis"), and 12 ("Perioperative Pulmonary Embolism or Deep Vein Thrombosis") contributed the greatest harm, with weights of 29.7%, 21.1%, and 20.4%, respectively. Regarding reliability, the overall average hospital signal-to-noise ratio for the reweighted PSI 90 was 0.7015. Regarding discrimination, among hospitals with greater than median volume, 34% had significantly better PSI 90 performance, and 41% had significantly worse performance than benchmark rates (based on percentiles). Reformulation of PSI 90 with harm-based weights is feasible and results in satisfactory reliability and discrimination, with a more clinically meaningful distribution of component weights.

Ultrasound-accelerated thrombolysis in high-risk perioperative pulmonary embolism: two case reports and review of literature

IntroductionTreatment of high-risk pulmonary embolism (PE) in perioperative patients remains challenging. Systemic thrombolysis is associated with a high risk of major bleedings and intracranial haemorrhage. High mortality rates are reported for open pulmonary embolectomy. Therefore, postoperative surgical patients may benefit substantially from catheter-directed ultrasound-accelerated thrombolysis (USAT).Case presentationWe report two cases of high-risk perioperative PE. Both patients developed severe haemodynamic instability leading to cardiac arrest. After the implantation of a veno-arterial extracorporeal membrane oxygenation (ECMO), they were both successfully treated with USAT. Adequate improvement of right ventricular function was achieved; thus, ECMO could be successfully weaned after 3 and 4 days, respectively. Both patients showed favourable outcomes and could be discharged to rehabilitation.ConclusionCurrent guidelines on treatment of PE offer no specific therapies for perioperative patients with high-risk PE. However, systemic thrombolysis is often excluded due to the perioperative setting and the risk of major bleeding. Catheter-directed thrombolysis was shown to utilise less thrombolytic agent while obtaining comparable thrombolytic effects. The risk for major bleeding (including intracranial haemorrhage) is also significantly lowered. Until further trials determining the value of adopted treatment strategies of high-risk PE in perioperative patients are available, USAT should be considered in similar cases.

Risks and Outcomes of Perioperative Pulmonary Embolism in Major Surgeries: A Population-Based Study

Perioperative pulmonary embolism (PE) is a significant cardiovascular complication in many surgeries. This study aimed to investigate the risks and outcomes of perioperative PE in major surgery. Discharge records of the Nationwide Readmission Database from 2010 to 2015 were extracted and analyzed. Length of stay, charges, death, and 30-day hospital readmission rate were compared for patients with and without perioperative PE. In addition, surgery-specific risk factors and therapies associated with PE were explored in a multivariable model. A total of 12,376,153 hospitalizations for major surgeries were involved, and perioperative PE occurred in 22,676 hospitalizations (0.18%). The length of stay, charges, rate of death, and 30-day hospital readmission were higher in patients with perioperative PE than in those without perioperative PE. Respiratory (odds ratios [OR], 2.09; 95% CI, 1.89-2.3), cardiovascular (OR, 1.62; 95% CI, 1.51-1.73), and musculoskeletal (OR, 1.22; 95% CI, 1.1-1.29) surgeries were risk factors for the occurrence of perioperative PE. In patients with perioperative PE, respiratory surgery was a risk factor for death (OR, 1.48; 95% CI, 1.10-2.00), whereas gynecologic/obstetric surgery was a protective factor for 30-day readmission (OR, 0.30; 95% CI, 0.10-0.88). Regarding therapy for perioperative PE, thrombolytic therapy (OR, 1.74; 95% CI, 1.26-2.42) and embolectomy (OR, 3.60; 95% CI, 2.35-5.51) were risk factors for death. Respiratory, cardiovascular, and musculoskeletal surgeries were risk factors for the occurrence of perioperative PE and death. Future research on precise models to predict PE in major surgeries is needed for appropriate interventions to improve outcomes of perioperative PE.

Outcomes from the Use of Perioperative Extracorporeal Membrane Oxygenation in Patients Undergoing Thoracic Surgery: An 8-Year Single-Center Experience.

BackgroundExtracorporeal membrane oxygenation (ECMO) plays an important role in thoracic surgery. This retrospective study from a single center aimed to evaluate patient outcomes from the use of perioperative ECMO in 22 patients undergoing thoracic surgery during an 8-year period.Material/MethodsData were collected retrospectively from 22 patients who received ECMO (veno-arterial and veno-venous ECMO) as perioperative treatment during general thoracic surgery from January 2012 to October 2020. Patients required ECMO due to perioperative cardiopulmonary resuscitation (CPR) (2 cases), perioperative pulmonary embolism (PE) (2 cases), lung transplant (4 cases), undergoing complicated thoracic surgery (5 cases), postoperative acute respiratory distress syndrome (ARDS) (6 cases), and thoracic trauma (3 cases).ResultsVeno-arterial ECMO was used for circulatory support in 13 cases and veno-venous ECMO was used for respiratory support in 9 cases. The average ECMO support time was 71.6±42.4 h. Twenty patients (90.9%) were successfully decannulated and 17 (77.2%) survived to discharge. Complications included severe hemorrhage (3/22 patients, 13.6%), sepsis (3/22, 13.6%), and destruction of blood cells (1/22, 4.5%). There were no significant differences in survival rates between patients receiving pre- or postoperative ECMO (P=0.135) or between veno-venous ECMO (V-V ECMO) and veno-arterial ECMO (V-A ECMO) (P=0.550).ConclusionsThe findings from this small retrospective study from a single center showed that perioperative ECMO improved cardiac and respiratory function in patients undergoing thoracic surgery. Optimal results require surgeons to have an understanding of the indications and ability to control the complications of ECMO.

Impact of Perioperative Thromboembolic Complications on Future Long-term Risk of Venous Thromboembolism among Medicare Beneficiaries Undergoing Complex Gastrointestinal Surgery

BackgroundVenous thromboembolism (VTE), including deep venous thrombosis (DVT) and pulmonary embolism (PE), represents a common cause of morbidity and mortality following complex gastrointestinal surgery. Whether perioperative VTE also exposes patients to a higher long-term risk of VTE events remains poorly defined. MethodsThe Medicare 100% Standard Analytic Files were used to identify patients undergoing esophageal, hepatic, pancreatic, and colorectal resection between 2013 and 2017. The impact of perioperative VTE, defined as a VTE episode occurring during the index hospitalization or within 30 days of discharge, on the risk of developing subsequent long-term VTE episodes (i.e., more than 30 days following discharge) was examined. ResultsAmong 253,212 patients who underwent complex gastrointestinal surgery, 1.9% (n=4763) developed a VTE episode perioperatively. With a median follow-up period of 553 days (IQR 194–1052), a total of 11,052 patients (4.4%) developed a long-term VTE episode. Of note, patients who developed a DVT perioperatively had a higher risk of experiencing a long-term VTE episode than patients who had no perioperative thromboembolic complications (HR 6.50, 95%CI 6.04–6.98). The increase in risk was more pronounced among patients who had a PE (HR 27.97, 95%CI 25.39–30.80) at the time of surgery. Risk factors for long-term thromboembolic events following complex GI surgery included Black patients (HR 1.20, 95%CI 1.11–1.30), receipt of surgery at a teaching hospital (HR 1.09, 95%CI 1.04–1.13), nonelective surgery (HR 1.19, 95%CI 1.14–1.24), as well as a diagnosis of cancer (HR 1.10, 95%CI 1.05–1.16). The development of a perioperative DVT was associated with an increased long-term risk of VTE in both cancer (HR 5.59, 95%CI 5.29–6.61) and non-cancer patients (HR 6.98, 95%CI 6.37–7.64). Similarly, experiencing a PE at the time of surgery led to a higher long-term risk of VTE in cancer (HR 24.30, 95%CI 21.08–28.02), as well as non-cancer (HR 30.81, 95%CI 27.01–35.15) patients. ConclusionsPatients with a history of perioperative VTE had a higher risk of developing subsequent VTE events within 1–2 years following complex GI surgery. The risk was more pronounced among patients who had perioperative PE rather than DVT. These findings were consistent among both cancer and non-cancer patients.

Suspected Pulmonary Embolism in the First 2,000 Incidents Reports of Perioperative and Anesthetic Adverse Events in Thailand (PAAd Thai) Study

Background: Perioperative pulmonary embolism (PE) is a rare but life-threatening complication. The diagnosis remains challenging due to non-specific clinical presentations, which may vary from asymptomatic to cardiovascular collapse. Objective: To describe the clinical presentation, diagnosis, and outcomes of the patients after suspected PE as well as to investigate the cause among Thai surgical population. Materials and Methods: The authors conducted an observational study by retrospective analysis of the data from the Perioperative and Anesthetic Adverse Events in Thailand (PAAd Thai) study. All surgical patients under anesthesia in 22 participating hospitals between January 1 and December 31, 2015, were included. The incident reports of suspected PE were reviewed independently by three anesthesiologists. Data regarding patient characteristics, clinical manifestation, and other details were obtained from the standardized incident report forms. Descriptive statistics was used. Results: Of the 2,000 incident reports, 16 patients were diagnosed with suspected PE. Cardiac arrest occurred in 11 cases (68.7%) and the overall mortality rate was 37.5% (6 of 16 patients). Most incidents were reported in orthopedic patients (10 cases, 62.5%) and caused by thrombosis (13 cases, 81.2%). Most of the incidents occurred intraoperatively (10 cases, 62.5%). The confirmatory imaging studies were investigated in eight cases (50%). To minimize the adverse outcomes, having more experience along with the help from experienced assistants and improved multidisciplinary support, were predominantly recommended. In addition, the most frequent suggested corrective strategies were implementation of appropriate clinical practice guideline and quality assurance activity. Conclusion: Perioperative PE causes significant morbidity and mortality. The diagnosis remains difficult but early detection of suspicious clinical presentation and optimization of the treatment are crucial. Identification of high-risk patients, intraoperative vigilance, and effective interdepartmental communication should be considered to improve patient outcomes. Keywords: Perioperative, adverse event, anesthesia, pulmonary embolism, thromboembolic, complication

Impact of Malignancy on Thrombotic Complications and Mortality After Lower Extremity Endovascular Revascularization

The prevalence of malignancy in patients undergoing lower extremity revascularization is rare, however this population may increase in the future as cancer treatments progress and patient longevity improves. Malignancy is known to create a hypercoagulable or prothrombotic state due to the ability of tumor cells to activate the coagulation system. Here we conduct an observational study using 2011 to 2017 National Surgical Quality Improvement Program data to evaluate the incidence of thrombotic complications in patients with disseminated cancer undergoing lower extremity endovascular revascularization. We identified all patients who underwent lower extremity endovascular revascularization between 2011 and 2017 in the American College of Surgeons National Surgical Quality Improvement Program targeted vascular module. Lower extremity revascularization included femoropopliteal angioplasty/stenting/atherectomy and tibial angioplasty/stenting. We compared odds ratios of perioperative thrombotic complications and mortality between patients with disseminated cancer and those without using a multivariate logistic regression model. We identified 11,574 lower extremity endovascular revascularization procedures, of which 60 were patients with disseminated cancer and 11,514 without. The distribution of indication for revascularization in the disseminated cancer group was as follows: 18.3% for claudication, 30.0% for rest pain, and 48.3% for tissue loss. We used multivariate logistic regression analysis controlling for age, gender, diabetes, smoking status, history of chronic obstructive pulmonary disease, and history of congestive heart failure to evaluate the risk of thrombotic complications. Patients with disseminated cancer had an odds ratio (OR) of 19.5 (95% confidence interval [CI], 2.4-158.8; P = .005) of pulmonary embolism compared to patients without malignancy, an OR of 4.2 (95% CI 1.3-13.6; P = .017) of myocardial infarction, and an OR of 4.0 (95% CI 0.95-17; P = .059) of 30-day mortality. The OR of perioperative mortality conferred by disseminated cancer is less than that of congestive heart failure, which has an OR of 5.8 (95% CI 3.5-9.5; P < .001). Interestingly enough, there was zero incidence of DVT, stroke, or arterial thrombosis in the disseminated cancer group in the National Surgical Quality Improvement Program database, so the logistic regression model could not be applied for these outcomes. Patients with disseminated cancer are currently a small cohort of patients undergoing endovascular lower extremity intervention. However, the National Surgical Quality Improvement Program outcomes indicate that the risk of perioperative pulmonary embolism and myocardial infarction is higher in this cohort, although there is insufficient data to evaluate deep vein thrombosis, stroke, or arterial thrombosis risk. Further study using granular data from the Vascular Quality Initiative is warranted, as well as evaluating the effect of anticoagulation in this subset of patients with increased thrombotic risk.

Incidence of postsurgical pulmonary embolism and deep venous thrombosis: a single-center retrospective observational study

BackgroundCancer is a risk factor for perioperative deep venous thrombosis and pulmonary embolism (DVT/PE). However, there is a paucity of data on non-malignant digestive diseases. In this study, we aimed to investigate the incidence of DVT/PE among patients, following surgery for acute appendicitis and other digestive diseases.MethodsWe retrospectively reviewed the records of patients who underwent surgical procedures involving the digestive system between April 2018 and March 2019 attended by anesthesiologists (n = 536).ResultsDVT/PE developed in seven patients (7/77, 9.1%, 95% confidence interval [CI] 3.7–17.8%) after surgery for acute appendicitis, and in six patients (6/83, 7.2%, 95%CI 2.7–15.1%) after elective surgery for colorectal cancer. Among the acute appendicitis group, six patients (6/30 20.0%) with complicated appendicitis (gangrenous or perforated appendicitis), and one patient (1/47 2.1%) with simple appendicitis showed postoperative DVT/PE. Patients with complicated appendicitis had a higher risk of DVT/PE than those with simple appendicitis with an odds ratio of 11.5 (95%CI 1.3–101.1).ConclusionsAlthough patients with acute appendicitis lack three of the risk factors for DVT/PE (cancer, long operative time, and older age), their 95% CI for the incidence of DVT/PE was comparable to that of patients undergoing elective surgery for colorectal cancer. Therefore, caution must be exercised during the perioperative period for preventing DVT/PE.

COT-20 PERIOPERATIVE STATUS OF SERUM D-DIMER LEVEL AND VENOUS THROMBOSIS IN PATIENTS WITH MALIGNANT BRAIN TUMOR

BACKGROUNDSThe patients with malignant brain tumors frequently show the hypercoagulability state and a decrease in fibrinolysis ability with an elevation in D-dimer. This is partially due to tumor-related hemiparesis or surgical stress including long-term bed-ridden positioning during and after operation,which could lead to development and extension of deep venous thrombosis (DVT) in lower extremities and eventually fatal pulmonary embolism.METHODSWe retrospectively examined the pre- and postoperative serum D-dimer levels and DVT state in 75 consecutive patients with malignant brain tumors (i.e. glioma,malignant lymphoma; mean age 64 yo,28 females) operated at our hospital from January 2015 to April 2017. Serial D-dimer levels were measured with the latex agglutination method (Roche) at 2 days before and right after operation,postoperative day (POD) 1,3,and 7. Lower limb venous ultrasound (LVUS) or contrast CT was performed if preoperative D-dimer was 0.5μg/ml or higher.RESULTSAverage BMI was 21.3,nine patients with diabetes mellitus,10 had recurrent diseases after chemotherapy,and 10 presented paresis in the lower extremities preoperatively while two developed transient paresis postoperatively. While two patients had prior DVT history,central and calf DVTs were identified preoperatively in one and 12 (15%) patients,respectively. Among four patients with re-elevation of D-dimer after POD 7,infection (2 patients),new DVT (2),and hemorrhagic events (gastrointestinal 2,including 1 death; epistaxis 2) developed,where a cut-off value D-dimer > 1.69 yielded sensitivity 100% and specificity 80%. Intraoperative intermittent calf compression prevented perioperative pulmonary embolism in those with calf DVT.CONCLUSIONSAppropriate perioperative DVT managements could prevent development of pulmonary embolisms in all patients with”high-risk” malignant brain tumors. Not only D-dimer > 1.5,but age of 80 or older,high preoperative D-dimer levels with calf DVT and taking DOAC may be risk factors for postoperative venous thromboembolism.

Investigation of the Incidence of Perioperative Pulmonary Embolism in Patients with Below-Knee Deep Vein Thrombosis after Lower Extremity Fracture and Evaluation of Retrievable Inferior Vena Cava Filter Deployment in These Patients

The objectives of the study were to investigate and compare the incidence of perioperative pulmonary embolism (PE) in trauma patients with below-knee deep vein thrombosis (BKDVT) and above-knee DVT (AKDVT) who need major orthopedic surgery and evaluate the usage of inferior vena cava (IVC) filters in these cases with BKDVT. Between January 2003 and December 2017, patients with pelvic and/or lower extremity fracture diagnosed with DVT by duplex ultrasound were eligible for the study. A reduced-dose anticoagulation therapy was administered in patients without absolute contraindication to anticoagulation therapy during the perioperative period. Patients who did not undergo filter insertion with BKDVT were classified as the BKDVT group, and cases with thrombosis involving the popliteal or more proximal veins were classified as the AKDVT group; the incidence of PE was analyzed. Among patients with BKDVT, cases with or without filter deployment were placed in the filter group and control group, respectively, to evaluate the value of IVC filter in these patients. A total of 3295 patients with pelvic and/or lower extremity fracture were diagnosed as having DVT, among which, 2070 cases did not undergo filter insertion. The incidence of PE in the BKDVT group and AKDVT group was 2.08% (24/1154) and 3.17% (29/916), respectively. A total of 366 patients with BKDVT underwent filter placement and no PE occurred. The incidence of PE in the filter group was lower than the control group. In patients without filter placement, the cases received anticoagulation therapy and those who did not, the incidence of PE was 2.21% and 1.94%, respectively, and there was no difference between the two subgroups. There was no difference in incidence of PE between the AKDVT and BKDVT groups. Reduced-dose anticoagulation therapy does not affect the rates of PE in trauma patients with BKDVT who require ongoing orthopedics operations. For these patients, placement of the retrievable filter may be considered.

Inferior Vena Cava Tumor Thrombus Dynamics and Perioperative Pulmonary Embolism: A Single-Center Experience

To analyze preoperative tumor thrombus progression and occurrence of perioperative pulmonary embolism (PE) in patients with inferior vena cava tumor thrombus resection. Retrospective analysis. University of Washington Medical Center. Patients who had undergone inferior vena cava tumor resection with thrombectomy from 2014 to 2017. Analysis of demographic, perioperative, and outcome data. Variables were compared between groups according to the level of tumor thrombus, the timing of the preoperative imaging, and the occurrence of perioperative PE. Incidence, outcomes, and variables associated with perioperative PE and sensitivity/specificity analyses for optimized preoperative imaging timing, broken into 7-day increments, were assessed. Fifty-six patients were included in this analysis. Perioperative PE was observed in 6 (11%) patients, intraoperatively in 5 patients and in the early postoperative period in 1 patient. Of the 5 patients with intraoperative PE, 2 died intraoperatively. Perioperative PE occurred in 1 patient with tumor thrombus level I, in 2 patients with level II, in 2 patients with level III, and in 1 patient with level IV. Risks of preoperative tumor thrombus progression were minimized if the imaging study was performed within 3 weeks for level I and II tumor thrombi and within 1 week for level III tumor thrombus. Perioperative PE was observed in patients with all levels of tumor thrombus. Fifty percent of perioperative PE were observed in patients with infrahepatic tumor thrombus. Post-imaging progression of tumor thrombus was unlikely if the surgery was performed within 3 weeks in patients with levels I or II tumor thrombus or within 1 week in patients with level III tumor thrombus.

Prophylactic use of the Angel® Catheter in a patient with paraneoplastic syndrome scheduled for surgical tumor resection: A case report and literature review

Introductio. The Angel? catheter (BiO2 Medical Inc, San Antonio, Texas, USA) is a novel device that combines a triple lumen central venous catheter with an inferior vena cava filter for prevention of pulmonary embolism (IVC filtercatheter). Case report. We present the case of a 53- yearold male patient with renal carcinoma and a history of recent deep venous thrombosis (DVT) on oral anticoagulation who was scheduled to undergo open radical nephrectomy. Because of concerns about the risks from documented pre-existing DVT, we decided to insert the Angel? catheter preoperatively in order to have central venous access during surgery and also to reduce the risk of perioperative pulmonary embolism. On the first postoperative day, active gastric bleeding was detected and nadroparine was stopped. Before removal of the Angel? catheter, a pre-removal cavagram revealed large thrombus mass in the catheter filter. Because of the presence of the thrombus mass, the catheter was removed surgically, after a permanent vena cava filter was inserted. Conclusion. This case suggests that the use of the Angel? IVC filter/3-lumen central catheter combination could be a reasonable option for pulmonary embolism prophylaxis in the patients at a high risk for DVT, such as the patients with malignant disease, paraneoplastic syndrome and chemotherapy who need to undergo surgery.

Incidence Rates of Postoperative Pulmonary Embolisms in Symptomatic and Asymptomatic Patients, Detected by Diagnostic Images - A Single-Center Retrospective Study.

Pulmonary embolism (PE) is a serious complication during the perioperative period. However, because most previous studies on the incidence of postoperative PE are based on symptoms, asymptomatic occurrences of PE have been overlooked, and the absolute incidence of postoperative PE remains unknown. The aim of this study was to investigate the incidence of perioperative PE, regardless of its symptoms, by reviewing the clinical interpretations of the diagnostic images obtained during the postoperative period. Methods and Results: This study included all patients aged at least 18 years who underwent operations under general and/or neuraxial anesthesia in our institution from 2013 to 2016. We reviewed all interpretations of the diagnostic imaging performed in the postoperative period. We analyzed the 90-day cumulative incidence of postoperative PE and the characteristics, risk factors, and symptoms of patients with and without postoperative PE. Among 21,763 operations, postoperative diagnostic imaging was performed in 1,168 patients, which found PE in 217 patients. Symptoms appeared in 11.1% (24/217) of the PE patients, and 66.7% of these symptoms were decreased levels of SpO2alone. Mortality from PE was 0.5% (1/217). Diagnostic imaging found a number of postoperative PE cases, regardless of the presence of symptoms. Although symptomatic PE was not a frequent occurrence, these findings suggest that clinicians should be aware of postoperative PE even under current prophylaxis.

The Patient Safety Indicator Perioperative Pulmonary Embolism or Deep Vein Thrombosis: Is there associated surveillance bias in the Veterans Health Administration?

BackgroundStudies disagree whether surveillance bias is associated with perioperative venous thromboembolism (VTE) performance measures. A prior VA study used a chart-based outcome; no studies have used the fully specified administrative data-based AHRQ Patient Safety Indicator, PSI-12, as their primary outcome. If surveillance bias were present, we hypothesized that inpatient surveillance rates would be associated with higher PSI-12 rates, but with lower post-discharge VTE rates. MethodsUsing VA data, we examined Pearson correlations between hospital-level VTE imaging rates and risk-adjusted PSI-12 rates and post-discharge VTE rates. To determine the robustness of findings, we conducted several sensitivity analyses. ResultsHospital imaging rates were positively correlated with both PSI-12 (r = 0.24, p = 0.01) and post-discharge VTE rates (r = 0.16, p = 0.09). Sensitivity analyses yielded similar findings. ConclusionsLike the prior VA study, we found no evidence of PSI-12-related surveillance bias. Given the use of PSI-12 in nationwide measurement, these findings warrant replication using similar methods in the non-VA setting.

Perioperative Pulmonary Embolism Prevention and Treatment

Perioperative Pulmonary Embolism Prevention and Treatment

Evaluation of nonpermanent inferior vena cava filter placement in patients with deep venous thrombosis after lower extremity fracture: A single-center retrospective study.

To investigate nonpermanent inferior vena cava (IVC) filter in the prevention of perioperative pulmonary embolism (PE) in patients of lower extremity and/or pelvic bone fracture with deep vein thrombosis (DVT). Lower extremity or pelvic bone fracture patients with lower extremity DVT hospitalized in our hospital from January 2003 to October 2014 were retrospectively analyzed. Data was analyzed for age, gender, position of fracture, position of proximal of thrombosis, indications of placement, complications, retrieval rate, and rate of entrapped filter clot. Patients who underwent IVC filter placement were selected as the filter group. The patients who did not perform IVC filter placement after 2008 and the cases between January 2003 and December 2007 were selected as control group 1 and control group 2, respectively. The incidence of perioperative symptomatic PE and mortality were analyzed. A total of 2763 cases complicated with DVT underwent orthopedic surgery between January 2003 and October 2014. 823 nonpermanent filters were inserted. All filters were successfully deployed with no major complications. After a mean 14.2 days indwelling time, all of temporary filters were removed. Retrieval was attempted in 556 patients with retrievable filters and was successful in 545 (98%); mean indwelling time was 16.3 days. The total retrieval rate was 90%. The incidence of PE in the filter group was significantly lower compared with the two control groups. Among the patients who received chemical anticoagulant therapy, the incidence of PE in filter group, control group 1 and control group 2 were 0.14%, 1.60% and 2.10%, respectively. The incidence of PE in filter group was also significant lower compared with control groups. Nonpermanent IVC filter placement seems like to be a safe and effective method for preventing perioperative symptomatic and fatal PE in bone fracture patients with DVT in the present retrospective study.

Factors associated with in-hospital pulmonary embolism after shoulder arthroplasty

Despite that pulmonary embolism (PE) is a feared complication after shoulder arthroplasty, little is known about its perioperative associated factors. We used the Nationwide Inpatient Sample to gather a sample of 422,372 patients who underwent shoulder arthroplasty between 2002 and 2011. This population was divided into 2 cohorts on the basis of those who experienced perioperative PE (0.25%) and those who did not. Demographics were compiled for both cohorts. Multivariable logistic regression analysis was used to account for confounding variables and to determine significant predictors of perioperative PE. After adjusting for patient demographic and clinical variables in multivariable regression modeling, the top 4 independent predictors for PE were primary diagnosis of proximal humerus fracture, deficiency anemia, congestive heart failure, and chronic lung disease. Other pertinent risk factors included increasing age, obesity, fluid and electrolyte abnormalities, undergoing total shoulder arthroplasty rather than hemiarthroplasty, and subsequent days of postoperative care. Knowledge of these factors might help in preoperative counseling and prove useful for implementation of quality improvement strategies to reduce the occurrence of PE. Surgeons may consider initiating thromboprophylaxis in patients with any of the aforementioned comorbidities.

Massive Pulmonary Embolism after Prolonged Spinal Fusion Surgery and the Golden Hour

Massive pulmonary embolism in the perioperative period almost inevitably leads to death if a delay in diagnosis and treatment occurs. The time window in which treatment should be initiated in order to reduce morbidity and mortality is very short; therefore a so-called golden hour for pulmonary embolism exists. Preoperatively, the role of ultrasound in the diagnosis of this potential life threating condition can be crucial. The present case report describes the role of transesophageal echocardiography after spinal fusion surgery in getting a timely diagnosis and treatment of massive perioperative pulmonary embolism.