I‑Wen Chena, Cheuk‑Kwan Sunb, Jen‑Yin Chenc,d, Chien‑Ming Lina, Kuo‑Chuan Hungc*
aDepartment of Anesthesiology, E‑Da Hospital, Kaohsiung, Taiwan, bDepartment of Emergency Medicine, E-Da Hospital and I-Shou University, Kaohsiung, Taiwan, cDepartment of Anesthesiology, Chi Mei Medical Center, Tainan, Taiwan, dDepartment of the Senior Citizen Service Management, Chia Nan University of Pharmacy and Science, Tainan, Taiwan
Open Access funded by Buddhist Compassion Relief Tzu Chi Foundation
Abstract
A 73‑year‑old male (height, 156 cm; body weight, 51 kg), without a history of cardiovascular disease or thromboembolic events, was scheduled for transurethral
resection of the prostate under spinal anesthesia. Spinal anesthesia was administered with hyperbaric bupivacaine, resulting in an upper anesthetic level of T6. Before surgery, compression stockings were applied to both lower limbs, and the patient was placed in the lithotomy position. Approximately 15 min later, he complained of intolerable chest tightness, followed by tachycardia (heart rate, 110 beats/min) and desaturation (oxygen saturation [SaO2], 90%). Tracheal intubation was performed immediately. The decrease in end‑tidal partial pressure of carbon dioxide (EtCO2) with an increase in the arterial carbon dioxide partial pressure‑EtCO2 gradient (16 mmHg) suggested pulmonary embolism (PE), which may have been induced by leg manipulation. The patient developed transient hypotension after tracheal intubation; however, his hemodynamic profile stabilized after inotropes administration. Subsequent tests showed normal cardiac enzyme levels; however, his D‑dimer levels increased significantly. Imaging confirmed deep vein thrombosis (DVT) and PE. Anticoagulation with warfarin was administered, and he was discharged on the postoperative day 11 without complications. In conclusion, DVT is often a cause of PE. Preoperative identification of DVT risk factors and respiratory symptoms as well as intraoperative monitoring of arterial SaO2 are vital for timely diagnosis of PE, especially in patients receiving intraoperative lower limb manipulation.
Keywords: Compression stockings, Lithotomy position, Pulmonary embolism, Spinal anesthesia
