Postoperative Acute Pulmonary Embolism Following Pulmonary Resections

Postoperative acute pulmonary embolism after pulmonary resections is highly fatal complication. Many literatures have documented cancer to be the highest risk factor for acute pulmonary embolism after pulmonary resections. Early diagnosis of acute pulmonary embolism is highly recommended and computed tomographic pulmonary angiography is the gold standard in diagnosis of acute pulmonary embolism. Anticoagulants and thrombolytic therapy have shown a great success in treatment of acute pulmonary embolism. Surgical therapies (embolectomy and inferior vena cava filter replacement) proved to be lifesaving but many literatures favored medical therapy as the first choice. Prophylaxis pre and post operation is highly recommended, because there were statistical significant results in different studies which supported the use of prophylaxis in prevention of acute pulmonary embolism.Having reviewed satisfactory number of literatures, it is suggested that thoroughly preoperative assessment of patient conditions, determining their risk factors complicating to pulmonary embolism and the use of appropriate prophylaxis measures are the key options to the successful minimization or eradication of acute pulmonary embolism after lung resections.     

普通外科医师如何识别和紧急救治肺动脉栓塞

肺动脉栓塞(PE)在普通外科病人中并不少见。普通外科医师有必要掌握诊断和治疗的基本知识,提高及时识别PE能力。在紧急抢救时,早期处理和快速启动会诊系统非常重要。发现病人存在PE的可疑临床表现和体征时,监测血D-二聚体,如果阳性启动Wells评分,当评分≥2分时,进行相关确诊检查。高度疑诊和确诊的高危PE的紧急救治需要区别对待,前者难度和风险更大,需要多学科团队的快速联合干预。     

Pulmonary emboli: the differential diagnosis dilemma

Pulmonary embolism is a rare but serious medical condition, with an estimated mortality of 5% to 20%. Many patients receiving physical therapy may be at risk for developing pulmonary embolism, especially after periods of immobilization or surgery. Patients presenting with dyspnea, chest pain, or tachypnea, particularly after trauma or surgery, have an increased likelihood of pulmonary embolism. Clinical prediction rules have been developed, which can aid the practitioners in assessing the risk a patient has for developing pulmonary embolism. The present clinical commentary discusses the existing evidence for screening patients for pulmonary embolism. To illustrate the importance of the screening examination, a patient is presented who was referred to physical therapy 5 days after cervical discectomy and fusion. This patient was subsequently referred for medical evaluation and a confirmatory diagnosis of pulmonary embolism.     

Pulmonary embolism after insertion of a Greenfield filter

This report describes a case in which a patient had a Greenfield filter placed at the time of diagnosis of deep vein thrombosis (DVT) when he was asymptomatic for pulmonary embolism. Later in the patient's hospital course, a typical clincal picture of pulmonary embolism developed. The issues examined in this report include: (1) the incidence of asymptomatic pulmonary embolism; (2) the value of the baseline ventilation perfusion (VQ) lung scan for the diagnosis of DVT; and (3) the value of an echocardiogram in diagnosing pulmonary embolism. It appears reasonable that patients in whom DVT is diagnosed undergo baseline VQ scanning. This procedure would prevent the misdiagnosis of a new pulmonary embolism while the patient is on anticoagulation therapy and possibly avoid unnecessary invasive diagnostic procedures. The case described demonstrates the usefulness of the echocardiogram and a transthoracic echo in the diagnosis of pulmonary embolism. It also points out the surprisingly high incidence of silent pulmonary embolism in patients in whom DVT is diagnosed.     

急性肺栓塞动物猪模型的建立及评价

目的 探讨数字减影血管造影（ DSA ）监测下,利用实验猪建立急性肺栓塞动物模型的可行性.方法 利用 15 头健康实验猪,在数字减影血管造影监测下,经股静脉穿刺,置入导丝及导管,到达右下肺动脉 2 - 3 级分支,将预先准备好的明胶海棉8 mm x 5 mm x 2 mm,经导管注入 5 个栓子,通过数字减影血管造影证实肺栓塞模型成功建立,同时观察实验猪于栓塞前和栓塞后 3 h 内不同时间段心率,血氧,肺动脉压,支气管黏膜的变化.造模成功后 4 h 处死动物,寻找右下肺动脉内的明胶海绵栓子.结果 15 头动物猪均能造模成功,在栓塞前和栓塞后不同时间心率升高,血氧饱和度下降,肺动脉压升高,栓塞前后有明显的统计学差异（ P 〈 0.001 ）,同时伴有支气管黏膜颜色改变,尸解后于右下肺动脉内可找到明胶海绵栓子.结论 数字减影血管造影监测下,建立急性肺栓塞模型方法可行,成功率高.临床监测符合人类改变,可作为临床医师对此疾病的培训和临床研究.     

Surgical treatment of massive pulmonary embolism. A case report

Pulmonary embolism is a serious complication following trauma and bed rest and it represents a challenge in the prompt diagnosis and medical or surgical therapy. We present a surgically treated patient with a massive pulmonary embolism (more than 50% of the vascular pulmonary bed) which occurred after an inferior leg trauma which required a prolonged bed immobilization. We believe surgical intervention is the treatment of choice in patients with massive pulmonary embolism who do not respond to fibrinolytic therapy. Moreover prompt surgical embolectomy is mandatory to have more chances to save the patient's life.     

Therapeutic effects of thromboembolectomy and caval Günther filter insertion in chronic pulmonary embolism

Two cases of chronic-stage pulmonary embolism which had occurred at least one month before the operation were presented. Pulmonary thromboembolectomy under the cardiopulmonary bypass was performed and followed by the insertion of Günther filter to prevent recurrence of embolism. Both cases revealed severe obstruction occupying over 50% of the pulmonary arteries which were presented by the remarkable increase of pulmonary arterial systolic pressures up to 100 and 80 mmHg respectively. After thrombectomy the pulmonary artery pressure declined to 45 and 28 mmHg, even though the pulmonary embolism was in subchronic state. The respiratory symptoms and abnormal findings on the ECG and chest X-ray were also improved. Since the phlebothrombosis of the inferior limb might be the cause of pulmonary embolism, the insertion of the filter in the inferior vena cava was thought to be indispensable for the prevention of recurrence.     

Pulmonary edema following air embolism

Venous air embolism is a major hazard during surgical procedures in the sitting position and is known to cause acute pulmonary edema in animal experiments (6, 7, 17). In man some cases of pulmonary edema immediately following air embolism have been described (10, 15, 16). In this case report we present a patient that developed pulmonary edema which became apparent several hours after the occurrence of air embolism.     

多排螺旋CT肺动脉造影与血浆D-二聚体水平对诊断肺动脉栓塞的意义

目的探讨多排螺旋CT肺动脉造影与D-二聚体检测水平对诊断肺动脉栓塞的价值。方法采用多排螺旋CT对34例肺动脉栓塞患者进行影像学表现与血浆D-二聚体水平的分析。结果 34例经MSCTPA诊断肺动脉栓塞的患者有30例血浆D-二聚体水平明显高于正常值,有4例阴性。结论血浆D-二聚体水平检测只能作为肺动脉栓塞初步筛选,MSCTPA是肺动脉栓塞最可靠、最直接的首选方法。     

Pulmonary embolism after operative treatment of proximal humeral fractures

There have been multiple studies on the prevalence of pulmonary embolism, the probability of death from a pulmonary embolism, and the risk factors for the development of pulmonary embolism after lower extremity and pelvic trauma. However, there is no information on the risk of pulmonary embolism after the surgical management of proximal humeral fractures. A review of 137 consecutive patients who underwent operative treatment for acute, isolated proximal humeral fractures at our institution between January 1, 1998, and December 31, 2003, was performed to identify all who sustained a pulmonary embolism. Postoperatively, 7 patients sustained a pulmonary embolism that was confirmed by computed tomography. Of these, 4 had been treated with a hemiarthroplasty and 3 had undergone open reduction-internal fixation. The overall incidence of pulmonary embolism in this series was 5.1%. None of the patients sustained a fatal pulmonary embolus. These data suggest that the rate of pulmonary embolism after operative treatment of proximal humeral fractures is not low. This study raises the question of whether prophylactic anticoagulation is needed after routine proximal humeral repair.     

原发性肝癌经导管肝动脉化疗栓塞术后肺栓塞4例临床分析

目的分析原发性肝癌经导管肝动脉化疗栓塞（TACE）术后并发肺栓塞的临床特点,探讨发生机制、早期诊断和治疗方法。方法2000年1月至2007年12月,在我院接受TACE的原发性肝癌患者31869人次,其中术后出现肺栓塞患者4例。回顾性分析该4例患者的临床特点及发病机制、诊断、治疗方式。结果TACE术后并发肺栓塞例数占同期我院TACE例数的0．02％;出现肺栓塞时间为术后0．5h～5d,患者表现为呼吸困难、紫绀、心悸、胸痛、黄疸、血尿及血PO2、SatO2下降等肺栓塞症状;本组死亡2例,死亡率50％。结论肺栓塞是原发性肝癌患者TACE术后的严重并发症,是碘油阻塞为主的多种栓塞因素共同作用的结果。本病起病急骤,死亡率高。肺动脉造影及D—Dimer是早期明确诊断的重要方法。     

Validity of index of suspicion for pulmonary embolism after hip arthroplasty

Pulmonary embolism after total hip arthroplasty is problematic, and intravenous heparin treatment in the absence of pulmonary embolism carries risk. Algorithms for treating pulmonary embolism often cite clinical index of suspicion as a basis for initiating intravenous heparin, but most information regarding variables to predict pulmonary embolism originate from studies of patients rather than only from patients who had arthroplasty. We studied the hypothesis that a more homogenous subpopulation, patients who had total hip arthroplasty, may have findings more accurately predictive of pulmonary embolism. One hundred fifty records of patients who had total hip arthroplasty who were suspected of having pulmonary embolism and who were evaluated for pulmonary embolism were assessed. Complaints, physical findings, heparinization status, and test results were analyzed with univariate and multivariate assessments to determine predictors of pulmonary embolism. No significant differences were found between patients with or without pulmonary embolism regarding subjective complaints, physical examination, blood gas results, electrocardiogram findings, radiographs of the chest, and imaging of the veins of the legs. All attempts to model these variables into an index of suspicion that accurately predicted pulmonary embolism were unsuccessful. We advise adherence to established treatment algorithms rather than clinical suspicion when deciding whether to initiate heparin therapy.     

Seltene Ursachen akuter, chirurgisch-interventionsbed��rftiger Lungenembolien

Acute pulmonary embolism of nonthrombotic origin is rare. The clinical course is often fatal. The triggers of the so-called nonthrombotic pulmonary embolism (NTPE) are multiple: human cells (adipocytes, amniotic cells, trophoblasts, tumor cells), bacteria, fungi, parasites, gases, and debris. According to retrospective studies, one has to assume that many pulmonary embolisms are not diagnosed correctly and promptly. Based on an extensive literature overview, this paper summarizes the possible triggers of a NTPE. A prompt and correct diagnosis of a pulmonary embolism can be life-saving. Identifing the trigger of a pulmonary embolism is crucial for the following therapy and further prophylaxis. In some cases, the trigger of the pulmonary embolism determines the initial therapy. In cases of acute pulmonary embolism because of debris, a surgical approach is inevitable in most cases.     

The capnograph, a reliable non-invasive monitor for the detection of pulmonary embolism of various origin

The wash-out curve in the capnogram is known to be a sign of pulmonary air embolism. This characteristic pattern is also seen in the case of pulmonary embolism of other nature. Capnographic recordings were studied retrospectively and 22 wash-out curves were found. The quantitative change in end-tidal carbon dioxide concentration was compared with the change in other, circulatory parameters known to change in the case of pulmonary air embolism. There proved to be a quantitative correlation between the decrease in end-tidal carbon dioxide concentration and the change in pulmonary artery pressure, central venous pressure and mean arterial pressure. The capnograph showed to be a reliable monitor for the detection of pulmonary embolism of various origin just like pulmonary artery pressure monitoring is. In cases with concomitant Doppler ultrasound detection, the capnograph showed to be a more reliable monitor for the detection of pulmonary air embolism as is the Doppler ultrasound device.     

An experimental model of pulmonary embolism

Previous experimental studies have contributed to the diagnosis and management of pulmonary embolism in patients. However, most experimental techniques to produce pulmonary embolism used material with a structure and composition quite unlike the pulmonary emboli which occur in patients. This report describes a method to induce pulmonary embolism by using a subcutaneously implanted prosthetic graft for thrombus formation. Dogs were prepared by anastomosis of the graft from the distally ligated carotid artery to the proximally ligated femoral artery to provide initial blood flow which led to gradual graft occlusion by laminar deposition of fibrin and blood elements. Seven of 10 animals examined developed a large quantity of formed thrombus within the graft 5 days following implantation. A subsequent intravenous administration of a quantity of 0.2 g/kg of animal weight produced a massive pulmonary embolus which caused hemodynamic alterations in all 36 animals studied and proved lethal in four. Pulmonary embolism was induced in 20 dogs and the systemic arterial pressure, pulmonary arterial pressure, pulmonary arterial blood flow, left atrial pressure, static and dynamic lung compliance were observed for a 2-hr period. One group of 10 dogs was subjected to pulmonary embolism using fresh autologous blood clot, and the other group of 10 dogs was subjected to formed thrombus obtained by gradual occlusion of a prosthetic graft anastomosed to the carotid and femoral arteries and placed subcutaneously. Neither group of animals demonstrated significant alterations of systemic blood pressure. However, two animals died and two other animals developed significant hypotension in the group of 10 animals subjected to formed thrombus pulmonary embolism. None of the animals subjected to autologous blood clot developed significant hypotension. The pulmonary artery pressure increased in animals subjected to clot but returned to control values within 60 min. A much larger increase in pulmonary artery pressure was observed following embolism using formed thrombus and the pulmonary artery pressure remained elevated for the duration of study. Pulmonary mean blood flow did not change significantly in dogs subjected to clot but decreased significantly for a 60-min period in dogs subjected to formed thrombus. Left atrial pressure increased and static and dynamic compliance decreased significantly in dogs subjected to formed thrombus embolism, but no significant changes occurred in dogs which received fresh blood clot. This study documented significant differences in hemodynamic and ventilatory alterations induced by material with different mechanical properties. In addition, these observations indicate that the approach to inducing pulmonary embolism using thrombus recovered from a subcutaneous graft represents a useful experimental technique for evaluation of pulmonary embolism.     

Role of spiral volumetric computed tomographic scanning in the assessment of patients with clinical suspicion of pulmonary embolism and an abnormal ventilation/perfusion lung scan.

BACKGROUND: A study was carried out to evaluate the potential place of spiral volumetric computed tomography (SVCT) in the diagnostic strategy for pulmonary embolism. METHODS: In a prospective study 249 patients with clinical suspicion of pulmonary embolism were evaluated with various imaging techniques. In all patients a ventilation/perfusion (V/Q) scan was performed. Seventy seven patients with an abnormal V/Q scan underwent SVCT. Pulmonary angiography was then performed in all 42 patients with a non-diagnostic V/Q scan and in three patients with a high probability V/Q scan without emboli on the SVCT scan. Patients with an abnormal perfusion scan also underwent ultrasonography of the legs for the detection of deep vein thrombosis. RESULTS: One hundred and seventy two patients (69%) had a normal V/Q scan. Forty two patients (17%) had a non-diagnostic V/Q scan, and in five of these patients pulmonary emboli were found both by SVCT and pulmonary angiography. In one patient, although SVCT showed no emboli, the angiogram was positive for pulmonary embolism. In one of the 42 patients the SVCT scan showed an embolus which was not confirmed by pulmonary angiography. The other 35 patients showed no sign of emboli. Thirty five patients (14%) had a high probability V/Q scan, and in 32 patients emboli were seen on SVCT images. Two patients had both a negative SVCT scan and a negative pulmonary angiogram. In one who had an inconclusive SVCT scan pulmonary angiography was positive. The sensitivity for pulmonary embolism was 95% and the specificity 97%; the positive and negative predicted values of SVCT were 97% and 97%, respectively. CONCLUSIONS: SVCT is a relatively noninvasive test for pulmonary embolism which is both sensitive and specific and which may serve as an alternative to ventilation scintigraphy and possibly to pulmonary angiography in the diagnostic strategy for pulmonary embolism.     

Pulmonary embolism after placement of an Esmarch bandage for ankle surgery

We report the case of a woman scheduled for surgical fixation of an ankle fracture who developed a pulmonary embolism during application of an Esmarch compression bandage for exsanguination of the limb. Tracheal intubation and mechanical ventilation were needed to reanimate the patient and surgery had to be postponed 15 days. Orthopedic surgery, pneumatic tourniquets for providing a bloodless field and other risk factors contribute to the development of pulmonary embolism, which is often fatal. Accurate diagnosis by plasma D-dimer determination and imaging (perfusion scintigraphy, vascular Doppler ultrasound, echocardiography and pulmonary angiography) is discussed, along with therapeutic approaches to consider when managing pulmonary embolism.     

Massive pulmonary embolism

Massive pulmonary embolism is defined by systemic hypotension or cardiogenic shock. Clinically stable patients with right ventricular dysfunction on echocardiography, elevated brain natriuretic peptide or troponin are usually considered as having sub-massive pulmonary embolism, but this definition is not universally accepted. The time-lag to confirm massive pulmonary embolism should be kept as short as possible and every effort should be done to rely on bedside tests and to avoid patient transfer to the radiology department. D-dimer tests are useless in this setting and the diagnosis is mainly based on clinical probability and bedside echocardiography. When clinical probability is high, right ventricular dilatation assessed by echocardiography allows confirming the diagnosis without additional testing. On the other hand a normal echocardiography does not allow excluding pulmonary embolism. In this setting, a spiral computed tomography is mandatory after the patient has been stabilized. Anticoagulant treatment should be started as soon as pulmonary embolism has been suspected. Supportive care includes oxygen, fluid loading and inotropes. There is little doubt that thrombolytic treatment is of value in patients with massive pulmonary embolism. Conversely, the use of thrombolytic therapy in patients with so-called sub-massive pulmonary embolism remains controversial. Current data do not confirm that thrombolytic therapy decreases mortality in those patients but cannot exclude a clinically significant benefit. A large randomised comparison of heparin and thrombolysis in patients with sub-massive pulmonary embolism is underway to answer this question. Surgical or catheter embolectomy is nowadays only rarely performed in patients with pulmonary embolism. This method can be undertaken in the few patients with persisting shock despite supportive care and who have an absolute contraindication for thrombolytic therapy. Before new data are available there is no special indication for vena cava interruption in patients with massive pulmonary embolism.     

肺栓塞的影像学诊断与介入治疗

影像学检查是目前临床对疑诊肺栓塞的病人进行筛查的一线检查方法,但在影像学表现特点和诊断的准确性等方面尚未达成共识。同时,介入治疗的原理及不同治疗方法间的疗效差别也未有定论。本文就肺栓塞的影像学诊断与介入治疗方法作一综述。     

Experience of four cases of postoperative pulmonary embolism requiring surgical treatment

Four patients underwent a pulmonary embolectomy using cardiopulmonary bypass for acute pulmonary embolism which had occurred after various operations. In two cases, dehydration due to either diabetes insipidus or ileus had existed. In two cases, pulmonary embolism suddenly occurred in our hospital. In the remainder, the disease occurred in the previous hospitals and its diagnosis was established on the 6th and 7th postoperative days, respectively. In massive pulmonary embolism, echocardiography and/or enhanced chest CT are useful for prompt and noninvasive diagnosis. Thrombolytic therapy was performed in only one case before surgical embolectomy, which was not effective. Three patients were discharged without any postoperative complications, but one requiring preoperative external cardiac massage died of multiple organ failure 9 days after operation. Acute pulmonary embolism is one of the fatal postoperative complications. Recognition of this entity, and prompt diagnosis and treatment are essential for managing the fatal disease. Even in the early postoperative period, embolectomy using cardiopulmonary bypass is a safe and effective treatment.