Mridu Paban Nath, Nitya Nand Kumar, Malavika Barman and Rajib Kr Bhattacharyya
Acute massive pulmonary embolism is a life-threatening emergency with a very high mortality. A 34 year old man, presented in our emergency department with complaints of NYHA class-III dyspnoea, cough, palpitation, and left sided chest pain. The clinical findings and investigations suggest diagnosis of pulmonary embolism followed by confirmation with CT angiography. The patient was taken to the operation theatre with supported hemodynamically with dobutamine infusion. Using required monitors, anesthetic induction was done with etomidate and fentanyl followed by the tracheal intubation with rocuronium. During induction, there was sudden hypotension which was managed with fluid boluses and norepinephrine boluses and continuing infusion of dobutamine. Anaesthesia was maintained with 50% oxygen with air, pancuronium, fentanyl and midazolam. After midline sternotomy, using Cardiopulmonary Bypass (CPB), thromboembolectomy was done on warm beating heart without aortic cross-clamping or cardioplegia. Partially organized thrombi were removed from left and right pulmonary arteries and their distal branches. The patient was weaned successfully from CPB with inotropic supports. The patient was extubated in the surgical ICU. The patient was discharged on the 5th postoperative day uneventfully. The management of pulmonary embolism tests the skills of the anesthetist with respect to rapid haemodynamic management, management during CPB and difficulty in weaning successfully off CPB, using appropriate combination of inotropes and vasodilators.
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