Case Report
Acute pulmonary embolism during an endoscopic retrograde cholangiopancreatography Nate P. Painter, Priya A. Kumar, Harendra Arora Department of Anesthesiology, University of North Carolina, Chapel Hill, North Carolina, USA
ABSTRACT
Received: 30‑09‑13 Accepted: 29‑01‑14
A 76‑year‑old female patient presented for an endoscopic retrograde cholangiopancreatography (ERCP) for the removal of a biliary stent and lithotripsy. During the procedure, an acute drop in the end‑tidal CO2, followed by cardiovascular collapse prompted the initiation of the advanced cardiac life support protocol. Transesophageal echocardiography (TEE) demonstrated direct evidence of pulmonary embolism. The patient was promptly treated with thrombolytic therapy and subsequently discharged home on oral warfarin therapy, with no noted sequelae. Although, there have been case reports of air embolism during an ERCP presenting with cardiovascular collapse, to the best of our knowledge, there are no reported cases of acute pulmonary embolus during this procedure. While the availability of TEE in the operating suites is quite common, quick access and interpretation capabilities in remote locations may not be as common. With the expansion of anesthesia services outside of the operating rooms, it may be prudent to develop rapid response systems that incorporate resources such as TEE and trained personnel to deal with such emergent situations. Key words: Endoscopic retrograde cholangiopancreatography, Pulmonary embolism, Transesophageal echocardiography
INTRODUCTION
Videos available on www.annals.in
Access this article online
Website: www.annals.in PMID: *** DOI: 10.4103/0971-9784.129865 Quick Response Code:
A 76‑year‑old female presented for an endoscopic retrograde cholangiopancreatography (ERCP) for the removal of a biliary stent and lithotripsy. During the procedure, an acute drop in the end‑tidal CO2 (ETCO 2) followed by cardiovascular collapse prompted the initiation of advanced cardiac life support (ACLS) protocol. Transesophageal echocardiography (TEE) demonstrated direct evidence of pulmonary embolism. The patient was promptly treated with thrombolytic therapy and subsequently discharged home on oral warfarin therapy, with no noted sequelae. CASE REPORT A 76‑year‑old female patient (body mass index ‑31.8 kg/m2) presented, as an outpatient, to our gastrointestinal (GI) suite for an ERCP procedure for the removal of a biliary stent and
lithotripsy. She had a history of hypertension, hyperlipidemia and non‑insulin dependent diabetes mellitus and had been hospitalized within a month for choledocholithiasis, requiring an ERCP and stent placement. There was a remote history of smoking, but no history of cancer, deep venous thrombosis (DVT), or coagulation disorders. After an uneventful induction of general anesthesia and endotracheal intubation, the patient was positioned prone for the procedure. Approximately 35‑min after the ERCP was started; the ETCO2 was noted to have decreased from 36 to 2 mmHg within a few seconds. The patient was emergently turned supine and endotracheal tube placement verified under direct visualization. Although the electrocardiogram monitor displayed a normal sinus rhythm, the peripheral and carotid pulses were not palpable. Cardiopulmonary resuscitation (CPR) and ACLS protocol for pulseless electrical activity arrest was
Address for correspondence: Dr. Harendra Arora, Department of Anesthesiology, N2198 University of North Carolina Hospitals, Campus Box 7010, Chapel Hill, NC 27599 ‑ 7010, USA. E‑mail: [email protected]
Annals of Cardiac Anaesthesia Vol. 17:2 Apr-Jun-2014
145
Painter, et al.: Acute pulmonary embolism during an ERCP
immediately initiated. Since our GI suite is located in the basement, three floors below our main operating rooms, additional help including TEE was immediately called for. The rhythm deteriorated to asystole, but after approximately 3 min of CPR and two boluses of epinephrine, the patient regained a sinus rhythm along with a palpable pulse. During CPR, the ETCO2 was in the mid‑20s suggesting effective chest compressions. After the return of spontaneous circulation (ROSC) the ETCO2 was noted to be in the upper 20s to low 30s. Central venous access and an arterial line were simultaneously obtained. An arterial blood gas was drawn immediately after ROSC showed a pH 7.39, PaCO2 39 mmHg, PaO2 354 mmHg with a base deficit of negative 6.7. The ETCO2 at this time was in the low‑30s. An epinephrine infusion was initiated to maintain hemodynamic stability. A discussion was initiated by the anesthesiologist with the intensive care unit (ICU) and cardiology teams, who were by now present in the GI suite, to help establish a diagnosis and plan for further management. The possibilities being actively considered were a cardiac catheterization to rule out an acute coronary syndrome and a computed tomography (CT) scan to rule out pulmonary embolus (PE). As the discussions were ongoing about the next course of action, a TEE was performed by the attending anesthesiologist, which showed global hypokinesis with mobile echogenic densities in the right atrium and the right ventricle, suggestive of PE [Figure 1, Videos 1 and 2]. Based on this finding, it was decided to withhold further investigations and to immediately initiate the PE treatment protocol. Tissue plasminogen activator (tPA, 100 mg over 2 hours) was administered and the patient was transferred to the intensive care unit on an epinephrine drip (2-10 mcg/min, titrated to effect). Additionally, anticoagulation with a heparin drip (5000 IU followed by an infusion to
Figure 1: Midesophageal right ventricular inflow-outflow view shows echogenic shadow in the right atrium (arrow)
146
maintain the APTT at 1.5-2.5 times the control value) was initiated. A subsequent lower extremity Doppler study showed intraluminal obstruction in the left common femoral, profunda femoris and superficial femoral veins. Vasopressors were weaned and the patient was extubated on the post‑operative day (POD)‑1. Of note, a transthoracic echocardiogram obtained on POD‑1 did not demonstrate any right atrial or ventricular enlargement, nor did it show the mobile echogenic densities visualized at the initial TEE examination. Since the patient still had to undergo the aborted ERCP, it was decided to proceed with an inferior vena cava (IVC) filter placement after a multi‑disciplinary risk‑benefit discussion with the patient. Following the placement of a removable Bard Meridian IVC filter on POD‑4, the patient underwent an uneventful ERCP with the removal of bile duct stones. The patient was discharged home on oral warfarin therapy on POD‑8 with no noted sequelae. At a 3‑month follow‑up visit, it was decided to remove the IVC filter and discontinue the warfarin therapy as per the recommendations from the hematologist. DISCUSSION Significant morbidity and mortality can be associated with acute PE during the perioperative period.[1] The exact frequency of acute PE affecting the hemodynamic stability of a patient under general anesthesia is not known. Risk factors for the development of acute PE include advanced age, obesity, neoplasia, congestive heart failure, pregnancy, acute myocardial infarction, oral contraceptives and immobilization.[2] There have been a few case reports of air embolism during an ERCP, likely from intramural dissection of insufflated air into the portal venous system, presenting similarly to our patient with cardiovascular collapse.[3,4] However, to the best of our knowledge, there are no reported cases of acute PE during an ERCP procedure. In patients experiencing acute hemodynamic compromise during non‑cardiac surgery, TEE has been shown to make a significant impact by establishing the diagnosis as well as guiding management.[5,6] Timely performance of TEE by trained physicians can assist in the rapid diagnosis of PE, thereby directing resuscitation of patients with hemodynamic instability from acute PE.[7] Although, it is less common to see thromboemboli in transit, indirect signs of pulmonary artery obstruction such as right ventricular dysfunction, leftward interatrial septal bowing and signs of pulmonary hypertension are commonly present to support the Annals of Cardiac Anaesthesia Vol. 17:2 Apr-Jun-2014
Painter, et al.: Acute pulmonary embolism during an ERCP
diagnosis of PE.[7] Once a diagnosis has been established, treatment choices include thrombolysis, IVC filter placement and surgical embolectomy. A high index of suspicion for a potentially lethal complication, such as PE, must be exercised in patients with risk factors. Our patient’s risk factors included advanced age and obesity. Although our patient led a somewhat sedentary life‑style, she was not completely immobile. It is possible that the 3‑h car ride to the hospital on the day of the procedure might have contributed to this risk. Although our current practice does not include routine Doppler screening for DVT, it could be considered in selected patients. In addition, the use of simple measures like sequential compression devices would be reasonable for non‑surgical procedures such as ERCP. Events like this in an off‑site anesthesia location pose a significant challenge, where imaging studies such as TEE are harder to carry out due to the lack of equipment and trained personnel. With an increasing need to provide anesthesia services in remote locations, monitoring equipment and resuscitation supplies including a code cart, ACLS medications and a defibrillator should be immediately available. Maintaining a high degree of suspicion in patients with risk factors as well as paying close attention to the available standard monitors such as ETCO2 can help in an expedited diagnosis of PE. In this particular situation, we were able to rapidly mobilize our resources from the main operating room, which led to a timely diagnosis and treatment. Direct evidence of thromboemboli on the TEE examination was confirmatory evidence of PE and therefore led to early medical intervention with thrombolytics and a positive outcome. Had TEE not been utilized in this situation, this patient would have likely undergone
Annals of Cardiac Anaesthesia Vol. 17:2 Apr-Jun-2014
further invasive testing such as cardiac catheterization or multidetector CT, possibly delaying the diagnosis or leading to an untoward outcome. While the availability of TEE in the operating suites is quite common, quick access and interpretation capabilities in remote locations may not be as common. With the expansion of anesthesia services outside of the operating rooms, it may be prudent to develop rapid response systems that incorporate resources such as TEE and trained personnel to deal with such emergent situations. REFERENCES 1.
2. 3.
4.
5.
6.
7.
Anderson FA Jr, Wheeler HB, Goldberg RJ, Hosmer DW, Patwardhan NA, Jovanovic B, et al. A population‑based perspective of the hospital incidence and case‑fatality rates of deep vein thrombosis and pulmonary embolism. The Worcester DVT Study. Arch Intern Med 1991;151:933‑8. Dehring DJ, Arens JF. Pulmonary thromboembolism: Disease recognition and patient management. Anesthesiology 1990;73:146‑64. Finsterer J, Stöllberger C, Bastovansky A. Cardiac and cerebral air embolism from endoscopic retrograde cholangio‑pancreatography. Eur J Gastroenterol Hepatol 2010;22:1157‑62. Goins KM, May JM, Hucklenbruch C, Littlewood KE, Groves DS. Unexpected cardiovascular collapse from massive air embolism during endoscopic retrograde cholangiopancreatography. Acta Anaesthesiol Scand 2010;54:385‑8. Memtsoudis SG, Rosenberger P, Loffler M, Eltzschig HK, Mizuguchi A, Shernan SK, et al. The usefulness of transesophageal echocardiography during intraoperative cardiac arrest in noncardiac surgery. Anesth Analg 2006;102:1653‑7. Shillcutt SK, Markin NW, Montzingo CR, Brakke TR. Use of rapid “rescue” perioperative echocardiography to improve outcomes after hemodynamic instability in noncardiac surgical patients. J Cardiothorac Vasc Anesth 2012;26:362‑70. Rosenberger P, Shernan SK, Body SC, Eltzschig HK. Utility of intraoperative transesophageal echocardiography for diagnosis of pulmonary embolism. Anesth Analg 2004;99:12‑6.
Cite this article as: Painter NP, Kumar PA, Arora H. Acute pulmonary embolism during an endoscopic retrograde cholangiopancreatography. Ann Card Anaesth 2014;17:145-7. Source of Support: Nil, Conflict of Interest: None declared.
147
Copyright of Annals of Cardiac Anaesthesia is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
Acute pulmonary embolism during an endoscopic retrograde cholangiopancreatography Nate P. Painter, Priya A. Kumar, Harendra Arora Department of Anesthesiology, University of North Carolina, Chapel Hill, North Carolina, USA
ABSTRACT
Received: 30‑09‑13 Accepted: 29‑01‑14
A 76‑year‑old female patient presented for an endoscopic retrograde cholangiopancreatography (ERCP) for the removal of a biliary stent and lithotripsy. During the procedure, an acute drop in the end‑tidal CO2, followed by cardiovascular collapse prompted the initiation of the advanced cardiac life support protocol. Transesophageal echocardiography (TEE) demonstrated direct evidence of pulmonary embolism. The patient was promptly treated with thrombolytic therapy and subsequently discharged home on oral warfarin therapy, with no noted sequelae. Although, there have been case reports of air embolism during an ERCP presenting with cardiovascular collapse, to the best of our knowledge, there are no reported cases of acute pulmonary embolus during this procedure. While the availability of TEE in the operating suites is quite common, quick access and interpretation capabilities in remote locations may not be as common. With the expansion of anesthesia services outside of the operating rooms, it may be prudent to develop rapid response systems that incorporate resources such as TEE and trained personnel to deal with such emergent situations. Key words: Endoscopic retrograde cholangiopancreatography, Pulmonary embolism, Transesophageal echocardiography
INTRODUCTION
Videos available on www.annals.in
Access this article online
Website: www.annals.in PMID: *** DOI: 10.4103/0971-9784.129865 Quick Response Code:
A 76‑year‑old female presented for an endoscopic retrograde cholangiopancreatography (ERCP) for the removal of a biliary stent and lithotripsy. During the procedure, an acute drop in the end‑tidal CO2 (ETCO 2) followed by cardiovascular collapse prompted the initiation of advanced cardiac life support (ACLS) protocol. Transesophageal echocardiography (TEE) demonstrated direct evidence of pulmonary embolism. The patient was promptly treated with thrombolytic therapy and subsequently discharged home on oral warfarin therapy, with no noted sequelae. CASE REPORT A 76‑year‑old female patient (body mass index ‑31.8 kg/m2) presented, as an outpatient, to our gastrointestinal (GI) suite for an ERCP procedure for the removal of a biliary stent and
lithotripsy. She had a history of hypertension, hyperlipidemia and non‑insulin dependent diabetes mellitus and had been hospitalized within a month for choledocholithiasis, requiring an ERCP and stent placement. There was a remote history of smoking, but no history of cancer, deep venous thrombosis (DVT), or coagulation disorders. After an uneventful induction of general anesthesia and endotracheal intubation, the patient was positioned prone for the procedure. Approximately 35‑min after the ERCP was started; the ETCO2 was noted to have decreased from 36 to 2 mmHg within a few seconds. The patient was emergently turned supine and endotracheal tube placement verified under direct visualization. Although the electrocardiogram monitor displayed a normal sinus rhythm, the peripheral and carotid pulses were not palpable. Cardiopulmonary resuscitation (CPR) and ACLS protocol for pulseless electrical activity arrest was
Address for correspondence: Dr. Harendra Arora, Department of Anesthesiology, N2198 University of North Carolina Hospitals, Campus Box 7010, Chapel Hill, NC 27599 ‑ 7010, USA. E‑mail: [email protected]
Annals of Cardiac Anaesthesia Vol. 17:2 Apr-Jun-2014
145
Painter, et al.: Acute pulmonary embolism during an ERCP
immediately initiated. Since our GI suite is located in the basement, three floors below our main operating rooms, additional help including TEE was immediately called for. The rhythm deteriorated to asystole, but after approximately 3 min of CPR and two boluses of epinephrine, the patient regained a sinus rhythm along with a palpable pulse. During CPR, the ETCO2 was in the mid‑20s suggesting effective chest compressions. After the return of spontaneous circulation (ROSC) the ETCO2 was noted to be in the upper 20s to low 30s. Central venous access and an arterial line were simultaneously obtained. An arterial blood gas was drawn immediately after ROSC showed a pH 7.39, PaCO2 39 mmHg, PaO2 354 mmHg with a base deficit of negative 6.7. The ETCO2 at this time was in the low‑30s. An epinephrine infusion was initiated to maintain hemodynamic stability. A discussion was initiated by the anesthesiologist with the intensive care unit (ICU) and cardiology teams, who were by now present in the GI suite, to help establish a diagnosis and plan for further management. The possibilities being actively considered were a cardiac catheterization to rule out an acute coronary syndrome and a computed tomography (CT) scan to rule out pulmonary embolus (PE). As the discussions were ongoing about the next course of action, a TEE was performed by the attending anesthesiologist, which showed global hypokinesis with mobile echogenic densities in the right atrium and the right ventricle, suggestive of PE [Figure 1, Videos 1 and 2]. Based on this finding, it was decided to withhold further investigations and to immediately initiate the PE treatment protocol. Tissue plasminogen activator (tPA, 100 mg over 2 hours) was administered and the patient was transferred to the intensive care unit on an epinephrine drip (2-10 mcg/min, titrated to effect). Additionally, anticoagulation with a heparin drip (5000 IU followed by an infusion to
Figure 1: Midesophageal right ventricular inflow-outflow view shows echogenic shadow in the right atrium (arrow)
146
maintain the APTT at 1.5-2.5 times the control value) was initiated. A subsequent lower extremity Doppler study showed intraluminal obstruction in the left common femoral, profunda femoris and superficial femoral veins. Vasopressors were weaned and the patient was extubated on the post‑operative day (POD)‑1. Of note, a transthoracic echocardiogram obtained on POD‑1 did not demonstrate any right atrial or ventricular enlargement, nor did it show the mobile echogenic densities visualized at the initial TEE examination. Since the patient still had to undergo the aborted ERCP, it was decided to proceed with an inferior vena cava (IVC) filter placement after a multi‑disciplinary risk‑benefit discussion with the patient. Following the placement of a removable Bard Meridian IVC filter on POD‑4, the patient underwent an uneventful ERCP with the removal of bile duct stones. The patient was discharged home on oral warfarin therapy on POD‑8 with no noted sequelae. At a 3‑month follow‑up visit, it was decided to remove the IVC filter and discontinue the warfarin therapy as per the recommendations from the hematologist. DISCUSSION Significant morbidity and mortality can be associated with acute PE during the perioperative period.[1] The exact frequency of acute PE affecting the hemodynamic stability of a patient under general anesthesia is not known. Risk factors for the development of acute PE include advanced age, obesity, neoplasia, congestive heart failure, pregnancy, acute myocardial infarction, oral contraceptives and immobilization.[2] There have been a few case reports of air embolism during an ERCP, likely from intramural dissection of insufflated air into the portal venous system, presenting similarly to our patient with cardiovascular collapse.[3,4] However, to the best of our knowledge, there are no reported cases of acute PE during an ERCP procedure. In patients experiencing acute hemodynamic compromise during non‑cardiac surgery, TEE has been shown to make a significant impact by establishing the diagnosis as well as guiding management.[5,6] Timely performance of TEE by trained physicians can assist in the rapid diagnosis of PE, thereby directing resuscitation of patients with hemodynamic instability from acute PE.[7] Although, it is less common to see thromboemboli in transit, indirect signs of pulmonary artery obstruction such as right ventricular dysfunction, leftward interatrial septal bowing and signs of pulmonary hypertension are commonly present to support the Annals of Cardiac Anaesthesia Vol. 17:2 Apr-Jun-2014
Painter, et al.: Acute pulmonary embolism during an ERCP
diagnosis of PE.[7] Once a diagnosis has been established, treatment choices include thrombolysis, IVC filter placement and surgical embolectomy. A high index of suspicion for a potentially lethal complication, such as PE, must be exercised in patients with risk factors. Our patient’s risk factors included advanced age and obesity. Although our patient led a somewhat sedentary life‑style, she was not completely immobile. It is possible that the 3‑h car ride to the hospital on the day of the procedure might have contributed to this risk. Although our current practice does not include routine Doppler screening for DVT, it could be considered in selected patients. In addition, the use of simple measures like sequential compression devices would be reasonable for non‑surgical procedures such as ERCP. Events like this in an off‑site anesthesia location pose a significant challenge, where imaging studies such as TEE are harder to carry out due to the lack of equipment and trained personnel. With an increasing need to provide anesthesia services in remote locations, monitoring equipment and resuscitation supplies including a code cart, ACLS medications and a defibrillator should be immediately available. Maintaining a high degree of suspicion in patients with risk factors as well as paying close attention to the available standard monitors such as ETCO2 can help in an expedited diagnosis of PE. In this particular situation, we were able to rapidly mobilize our resources from the main operating room, which led to a timely diagnosis and treatment. Direct evidence of thromboemboli on the TEE examination was confirmatory evidence of PE and therefore led to early medical intervention with thrombolytics and a positive outcome. Had TEE not been utilized in this situation, this patient would have likely undergone
Annals of Cardiac Anaesthesia Vol. 17:2 Apr-Jun-2014
further invasive testing such as cardiac catheterization or multidetector CT, possibly delaying the diagnosis or leading to an untoward outcome. While the availability of TEE in the operating suites is quite common, quick access and interpretation capabilities in remote locations may not be as common. With the expansion of anesthesia services outside of the operating rooms, it may be prudent to develop rapid response systems that incorporate resources such as TEE and trained personnel to deal with such emergent situations. REFERENCES 1.
2. 3.
4.
5.
6.
7.
Anderson FA Jr, Wheeler HB, Goldberg RJ, Hosmer DW, Patwardhan NA, Jovanovic B, et al. A population‑based perspective of the hospital incidence and case‑fatality rates of deep vein thrombosis and pulmonary embolism. The Worcester DVT Study. Arch Intern Med 1991;151:933‑8. Dehring DJ, Arens JF. Pulmonary thromboembolism: Disease recognition and patient management. Anesthesiology 1990;73:146‑64. Finsterer J, Stöllberger C, Bastovansky A. Cardiac and cerebral air embolism from endoscopic retrograde cholangio‑pancreatography. Eur J Gastroenterol Hepatol 2010;22:1157‑62. Goins KM, May JM, Hucklenbruch C, Littlewood KE, Groves DS. Unexpected cardiovascular collapse from massive air embolism during endoscopic retrograde cholangiopancreatography. Acta Anaesthesiol Scand 2010;54:385‑8. Memtsoudis SG, Rosenberger P, Loffler M, Eltzschig HK, Mizuguchi A, Shernan SK, et al. The usefulness of transesophageal echocardiography during intraoperative cardiac arrest in noncardiac surgery. Anesth Analg 2006;102:1653‑7. Shillcutt SK, Markin NW, Montzingo CR, Brakke TR. Use of rapid “rescue” perioperative echocardiography to improve outcomes after hemodynamic instability in noncardiac surgical patients. J Cardiothorac Vasc Anesth 2012;26:362‑70. Rosenberger P, Shernan SK, Body SC, Eltzschig HK. Utility of intraoperative transesophageal echocardiography for diagnosis of pulmonary embolism. Anesth Analg 2004;99:12‑6.
Cite this article as: Painter NP, Kumar PA, Arora H. Acute pulmonary embolism during an endoscopic retrograde cholangiopancreatography. Ann Card Anaesth 2014;17:145-7. Source of Support: Nil, Conflict of Interest: None declared.
147
Copyright of Annals of Cardiac Anaesthesia is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
