Abstract

Acute pulmonary thromboembolism (APTE) can be life-threatening. Early detection is more difficult for patients who lack of pathognomonic signs and symptoms of pulmonary embolism (PE). We report a case of orthopedic surgery under combined spinal epidural anesthesia (CSE). A 47 year-old man underwent surgery for fracture femur under CSE. No arterial and deep vein thrombosis (DVT) was found prior to the surgery, presented with the hypotension, recurrent bradycardia, and final diagnosis of PE made during intraoperative period. In the absence of drug reaction, acute MI and AV blocks, sudden onset of recurrent bradycardia and shock followed by sudden decrease in Pet CO2 and increase in PACO2, we should pay more attention to PE, which is an important differential diagnosis of refractory bradycardia with shock. In this context, rapid ECHO and USG of deep veins should be done to rule out APTE and underlying DVT respectively in operation theatre. Multidisciplinary consultation was started immediately. After discussion with the consultation team anticoagulation therapy was started and surgery was withheld and patient shifted to AICU but patient succumbed to death due to refractory bradycardia and shock inspite of treatment for pulmonary thromboembolism as per guideline. Pulmonary embolism is a rare and potentially high-risk perioperative situation, with a difficult diagnosis when presented with bradycardia and hypotension. The separation phenomenon of decrease in Pet CO2 and increase in PaCO2 might be a useful and suggestive sign along with ECHO and USG if ECG is not showing typical changes of PTE.

Keywords: Interoperative, acute pulmonary thrombo embolism, bradycardia, hypotension, combined spinal epidural anesthesia.