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LETTER TO THE EDITOR

Acute Hemodynamic Collapse After Induction of General Anesthesia for Emergent Pulmonary Embolectomy

Department of Anesthesiology and Intensive Care Medicine; Tübingen University Clinic; Tübingen, Germany (Rosenberger, Eltschig) Department of Anesthesiology, Perioperative and Pain Medicine; Brigham and Women’s Hospital; Harvard Medical School; Boston, Massachusetts; shernan{at}zeus.bwh.harvard.edu (Shernan)

In Response:

Webb and Arrowsmith (1) suggest that femoro-femoral cardiopulmonary bypass should be considered before inducing anesthesia in patients, on the basis of the possibility of acute hemodynamic deterioration after induction of anesthesia in these patients (2). Femoral cannulation can usually be performed without difficulty to prepare patients for cardiopulmonary bypass before the induction of general anesthesia (3). Indeed femoral cannulation is a possible alternative for patients undergoing surgical pulmonary embolectomy who have significant ventricular dysfunction or for those with anticipated difficult airways.

Nevertheless, we (4) have previously demonstrated that up to 26% of patients undergoing pulmonary embolectomy have extrapulmonary thromboemboli, primarily within the inferior vena cava. Manipulation during femoral cannulation may dislodge these extrapulmonary thromboemboli, which may subsequently lodge in the pulmonary circulation and cause additional hemodynamic instability. The incidence of this phenomenon is unknown. We believe that the most important aspect of managing patients undergoing surgical pulmonary embolectomy is vigilant preparation for the rapid institution of cardiopulmonary bypass.

REFERENCES

1. Webb ST, Arrowsmith JE. Acute hemodynamic collapse after induction of general anesthesia for emergent pulmonary embolectomy. Anesth Analg 2007;104:742.[Free Full Text]
2. Rosenberger P, Shernan SK, Shekar PS, et al. Acute hemodynamic collapse after induction of general anesthesia for emergent pulmonary embolectomy. Anesth Analg 2006;102:1311–5.[Abstract/Free Full Text]
3. Arrowsmith JE, Dunning JJ, Gray SJ, et al. Anesthesia for ventricular assist device placement. J Cardiothorac Vasc Anesth 2001;15:274–5.[Web of Science][Medline]
4. Rosenberger P, Shernan SK, Mihaljevic T, Eltzschig HK. Transesophageal echocardiography for detecting extrapulmonary thrombi during pulmonary embolectomy. Ann Thorac Surg 2004;78:862–6; discussion 866.

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