Intraoperative Thrombolysis of Massive Pulmonary Embolus During Spine Surgery: Case Report of Survival Complicated by Massive Bleeding and Review of the Literature

Holland, Ryan; Houten, John K.; Elsamragy, Shahenaz; Kim, Jinu; Leyvi, Galina; Kinon, Merritt D.

doi:10.1016/j.wneu.2020.10.018

Cited by 7 publications

(7 citation statements)

References 30 publications

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“…Intraoperatively however, establishing the correct diagnosis can be much more difficult. Electrocardiogram evidence of a pulmonary embolism, whether fat emboli or thrombus, include signs of right ventricular strain, ST and/or T wave changes, and atrial abnormalities ( 8 ). Respiratory signs of fat embolism syndrome include hypoxemia, decreased lung compliance, and decreased end-tidal CO 2 levels ( 8 , 15 , 20 ).…”

Section: Discussionmentioning

confidence: 99%

“…Electrocardiogram evidence of a pulmonary embolism, whether fat emboli or thrombus, include signs of right ventricular strain, ST and/or T wave changes, and atrial abnormalities ( 8 ). Respiratory signs of fat embolism syndrome include hypoxemia, decreased lung compliance, and decreased end-tidal CO 2 levels ( 8 , 15 , 20 ). Cardiovascular abnormalities include hypotension, tachycardia, and possibly non-perfusing cardiac rhythms such as ventricular fibrillation, ventricular tachycardia, or pulseless electrical activity, and complete loss of pulses ( 8 , 15 , 20 ).…”

Section: Discussionmentioning

confidence: 99%

“…Respiratory signs of fat embolism syndrome include hypoxemia, decreased lung compliance, and decreased end-tidal CO 2 levels ( 8 , 15 , 20 ). Cardiovascular abnormalities include hypotension, tachycardia, and possibly non-perfusing cardiac rhythms such as ventricular fibrillation, ventricular tachycardia, or pulseless electrical activity, and complete loss of pulses ( 8 , 15 , 20 ). Intraoperative transthoracic or transesophageal echocardiography can demonstrate signs of right heart failure, while the latter can demonstrate an identifiable thrombus within the main pulmonary vasculature ( 8 , 20 ).…”

Section: Discussionmentioning

confidence: 99%

“…Treatment of fat embolism syndrome is largely supportive, as there is no specific medication that can be given to reverse the pathology or to remove the fat emboli from the pulmonary vasculature ( 8 , 15 ). To maintain oxygen saturations, the patient often must be hyperventilated with 100% oxygen.…”

Section: Discussionmentioning

confidence: 99%

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Intraoperative fat embolism syndrome associated with implantation of titanium sacroiliac joint fusion implants: a report of two cases

Aretakis,

Farrell,

Ou-Yang

et al. 2024

J Spine Surg

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Background For patients undergoing long-construct fusion surgeries, simultaneous sacroiliac joint (SIJ) fusion is a growing trend in spine surgery. Some options for posterior SIJ fusion include 3D-printed triangular titanium implants or self-harvesting SIJ screws. Both implants require fixation within the sacrum and ileum. Fat embolism syndrome is a rare but known complication of lumbar pedicle instrumentation but has never been reported in association with SIJ fusion, regardless of implant type. We report the first two known cases of fat embolism associated with placement of SIJ fusion devices during long construct posterior spine fusion. Case Description Case 1—a 50-year-old female with multiple previous spine surgeries complicated by osteomyelitis/diskitis that was successfully eradicated, underwent T10-pelvis posterior spinal fusion (PSF), L4 pedicle-subtracting-osteotomy, and bilateral SIJ fusion. During implantation of each SIJ fusion device, the patient’s hemodynamic status deteriorated necessitating vasopressor support, intravenous fluid bolus, and hyperventilation, but quickly resolved. The case was completed without further issue, and she had an uneventful post-operative course. Case 2—a 71-year-old female with a past medical history of ankylosing spondylitis, previous L2–L5 PSF, rheumatoid arthritis on chronic steroids, underwent a T9-pelvis PSF, bilateral SIJ fusion, L4 pedicle subtraction osteotomy, T10–L1 Smith Peterson osteotomies. After implantation of the second SIJ fusion device, she became hypotensive and tachycardic, pulses were absent, and cardiopulmonary resuscitation was initiated. Pulses returned quickly, the index surgery was terminated, and she was transferred to the intensive care unit (ICU). In the ICU she was quickly weaned off the ventilator on post-operative day 1. On post-operative day 4, the patient returned to the operating room for completion of the surgery and had an extended, but uneventful, recovery afterwards. Conclusions We report on the first two known cases of fat embolism syndrome occurring immediately after implantation of SIJ fusion devices. Spine surgeons should be aware of this rare, but potentially fatal, complication. Collaboration with the anesthesia team and optimization of the patient’s hemodynamic status prior to implantation may help prevent catastrophic complications.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

See 2 more Smart Citations

Intraoperative fat embolism syndrome associated with implantation of titanium sacroiliac joint fusion implants: a report of two cases

Aretakis,

Farrell,

Ou-Yang

et al. 2024

J Spine Surg

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“…当院では，腹臥位からの体位交換時はSpO 2 ，心電図，end–tidal CO 2 などの観血的動脈圧以外の一部モニターを外していた。同様にモニターを外しており初期症状であるバイタルサインの変化を察知できずに 11)，心停止まで至った脊椎手術症例の報告もある 6)。今回2例とも，モニターは仰臥位復帰後早急に再装着され，バイタルサインの変化に早期に気づくことができた。モニター未装着となる時間を短縮することが，早期にPEの兆候を察知するために重要である。なお，PE発症時にSpO 2 低下はよくみられるが，より劇的な症例では急激にend–tidal CO 2 が低下することが知られており，脊椎手術中end–tidal CO 2 低下がPE発症覚知の一助となった報告もある 12)。当院では腹臥位から仰臥位への体位交換時，end–tidal CO 2 モニターを外していることがほとんどであった。end–tidal CO 2 モニターは，頭側で回路混線せずに装着したまま安全に体位交換できるため，今後の腹臥位療法では，装着を継続して体位交換することも，検討の余地がある。…”

Section: 考　　察unclassified

腹臥位から仰臥位へ体位交換時に肺血栓塞栓症を発症した重症COVID–19肺炎の2例(Two cases of pulmonary embolism after position change from prone position during mechanical ventilation due to severe COVID–19 pneumonia)

夏奈

健夫

裕一

et al. 2023

Nihon Kyukyu Igakukai Zasshi: Japanese Journal of Japanese Asso

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要旨　COVID–19肺炎では腹臥位呼吸療法の有効性が注目されている。今回，腹臥位から仰臥位への体位交換時に発症した肺血栓塞栓症を2例経験したので報告する。1例目は59歳の男性，発症11日目に人工呼吸を開始し，15日目から腹臥位呼吸療法を開始した。17日目に仰臥位へ体位交換した30分後より，SpO2が94%から85%へと低下し，心拍数も90bpmから120bpmへ上昇した。D–ダイマーが9.2μg/mLから22.5μg/mLへ上昇していたため，肺血栓塞栓症を疑い，造影CTで左肺動脈血栓が判明した。2例目は46歳の男性，発症13日目で人工呼吸を開始し，同日腹臥位呼吸療法を開始した。14日目に仰臥位へ体位交換した10分後より血圧低下，12分後からSpO2が97%から84%へと低下した。D–ダイマーが5.6μg/mLから48.1μg/mLへ上昇していたことと，心臓超音波検査で右心負荷所見がみられたことから肺血栓塞栓症を疑い，造影CTで左内頸静脈血栓と右肺動脈血栓が判明した。今回の2症例は，いずれも腹臥位から仰臥位に体位交換した際に肺血栓塞栓症を発症しており，いずれも中心静脈カテーテル挿入側の内頸静脈に血栓を認めた。長時間の腹臥位から仰臥位への体位交換は，内頸静脈血栓から肺血栓塞栓症を発症させる可能性が示唆され，バイタルサインに留意して行うことが望ましい。

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Intraoperative Thrombolysis of Massive Pulmonary Embolus During Spine Surgery: Case Report of Survival Complicated by Massive Bleeding and Review of the Literature

Cited by 7 publications

References 30 publications

Intraoperative fat embolism syndrome associated with implantation of titanium sacroiliac joint fusion implants: a report of two cases

Intraoperative fat embolism syndrome associated with implantation of titanium sacroiliac joint fusion implants: a report of two cases

腹臥位から仰臥位へ体位交換時に肺血栓塞栓症を発症した重症COVID–19肺炎の2例(Two cases of pulmonary embolism after position change from prone position during mechanical ventilation due to severe COVID–19 pneumonia)

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