Anesthetic management for intraoperative acute pulmonary embolism during inferior vena cava tumor thrombus surgery:A case report

BACKGROUND Acute pulmonary embolism(APE)is a rare and potentially life-threatening condition,even with early detection and prompt management.Intraoperative APE required specific ways for detecting since classic symptoms of APE in the awake patient could not be observed or self-reported by the patient under general anesthesia.CASE SUMMARY A 44-year-old man with a history of hepatic cell carcinoma was admitted for radical nephrectomy and tumor thrombectomy due to a newly found kidney tumor with inferior vena cava(IVC)tumor thrombus.APE that occurred during tumor thrombectomy with hypercapnia and desaturation.The capnography combined with the transesophageal echocardiography(TEE)provided a crucial differential diagnosis during the operation.The patient was continuously managed with aggressive intravenous fluid resuscitation and blood transfusion under continuous cardiac output monitoring to maintain hemodynamic stability.He completed the surgery under stable hemodynamics and was extubated after percutaneous mechanical thrombectomy by a certified cardiologist.There were no significant symptoms and signs or obvious discomfort in the patient’s self-report during visits to the general ward.CONCLUSION Under general anesthesia for IVC tumor thrombus surgery,a sudden decrease in end-tidal carbon dioxide is the initial indicator of APE,which occurs before hemodynamic changes.When intraoperative APE is suspected,TEE is useful in the diagnosis and monitoring before computer tomography pulmonary angiogram.Timely clinical impression and supportive treatment and intervention should be conducted to obtain a better prognosis.

A fast-track diagnostic and therapeutic strategy for acute pulmonary embolism patients at peri-operational period

Acute pulmonary embolism(APE) in operation room is a constant,lethal but treatable disease.A fast determination of APE in an operation room is currently difficult due to a non-specificity on its signs,symptoms,electrocardiograph findings,arterial blood gas abnormalities and chest X-rays.Clinically,an APE can automatically originate from a small and clinically asymptomatic embolus to massive,proximal emboli with shock during a scheduled surgery period.An accurate,brief and prompt diagnostic and therapeutic strategy for APE in a peri-operation period is crucial for anesthesiologists to make a decision on an appropriate clinical intervention to improve patients' outcomes.The purpose of this mini-review article is to illuminate a fast-track diagnostic and therapeutic strategy for APE patients in a perioperative period through a hybrid of the high sensitive and high specific viable diagnostic modality of D-dimer assay in conjunction with necessary emergent pulmonary angiography(EPA),including digital subtraction angiography(DSA),or a spiral computed tomography angiography(sCTA) for APE patients' diagnosis and treatment during operation.The postulated fast-track diagnostic and therapeutic strategy can effectively confirm or exclude highly suspected APE and simultaneously provide fast therapeutic opportunities for APE patients at an operative period.

Effects of aspirin on the expression of nuclear factor-κB in a rat model of acute pulmonary embolism

BACKGROUND:Acute pulmonary embolism(APE) is a disorder involving the pulmonary circulation resulting from a blockage of the pulmonary artery. The present study aimed to investigate the effects of aspirin on the nuclear factor-κB(NF-κB) activity in a rat model of APE.METHODS:A total of 108 healthy male Sprague-Dawley rats were randomly assigned into six groups(n=18 rats per group):control group,sham operation group,APE model group,and low-,medium- and high-dose aspirin groups. Six,24,and 72 hours after the induction of APE,rats in the low-,medium- and high-dose aspirin groups were given aspirin at a respective daily dose of 150,300,and 600 mg/kg by gavage for three consecutive days. Rats in the other groups were treated with equal volumes of normal saline. Six rats in each group were anesthetized with 10% chloral hydrate solution at each time point,and then the lung tissues were collected and analyzed using immunohistochemical staining.RESULTS:Positive immunohistochemical staining was present in the bronchial epithelial cells,alveolar cells,macrophages,and surrounding bronchial smooth muscle cells. When compared with the APE model group,the number of positive cells was signif icantly lower in the other groups at each time point(P<0.001). Statistically signif icant differences were also observed among the aspirin-treated groups at 6 hours(P<0.05,P<0.001). Compared with the APE model group,NF-κB protein expression was reduced in the other groups at each time point(P<0.05,P<0.001). Rats from the APE model group had thrombosis,damaged alveolar walls,and pulmonary hemorrhage,along with different degrees of inf lammatory cellular inf iltration at each time point. However,pathological changes such as pulmonary hemorrhage and inf iltration of inf lammatory cells were attenuated after the aspirin treatment.CONCLUSION:Aspirin can signifi cantly inhibit NF-κB activity in the lung of rats with APE in a dose-dependent manner,and can alleviate lung injury after APE.

Increasing angiotensin-converting enzyme(ACE)2/ACE axes ratio alleviates early pulmonary vascular remodeling in a porcine model of acute pulmonary embolism with cardiac arrest

BACKGROUND:Acute pulmonary embolism(APE)with cardiac arrest(CA)is characterized by high mortality in emergency due to pulmonary arterial hypertension(PAH).This study aims to determine whether early pulmonary artery remodeling occurs in PAH caused by massive APE with CA and the protective effects of increasing angiotensin-converting enzyme(ACE)2-angiotensin(Ang)(1-7)-Mas receptor axis and ACE-Ang II-Ang II type 1 receptor(AT1)axis(ACE2/ACE axes)ratio on pulmonary artery lesion after return of spontaneous circulation(ROSC).METHODS:To establish a porcine massive APE with CA model,autologous thrombus was injected into the external jugular vein until mean arterial pressure dropped below 30 mmHg(1 mmHg=0.133 kPa).Cardiopulmonary resuscitation and thrombolysis were delivered to regain spontaneous circulation.Pigs were divided into four groups of five pigs each:control group,APE-CA group,ROSC-saline group,and ROSC-captopril group,to examine the endothelial pathological changes and expression of ACE2/ACE axes in pulmonary artery with or without captopril.RESULTS:Histological analysis of samples from the APE-CA and ROSC-saline groups showed that pulmonary arterioles were almost completely occluded by accumulated endothelial cells.Western blotting analysis revealed a decrease in the pulmonary arterial ACE2/ACE axes ratio and increases in angiopoietin-2/angiopoietin-1 ratio and expression of vascular endothelial growth factor(VEGF)in the APE-CA group compared with the control group.Captopril significantly suppressed the activation of angiopoietin-2/angiopoietin-1 and VEGF in plexiform lesions formed by proliferative endothelial cells after ROSC.Captopril also alleviated endothelial cell apoptosis by increasing the B-cell lymphoma-2(Bcl-2)/Bcl-2-associated X(Bax)ratio and decreasing cleaved caspase-3 expression.CONCLUSION:Increasing the ACE2/ACE axes ratio may ameliorate pulmonary arterial remodeling by inhibiting the apoptosis and proliferation of endothelial cells after ROSC induced by APE.

Changes and Significance of Cytokines in Serum of Rabbits with Acute Pulmonary Embolism

Objective:To observe the changes of cytokines in serum of rabbits with acute pulmonary embolism,and to provide a scientific basis for clinical treatment of the disease.Methods:The animal models of pulmonary embolism were established in 26 healthy rabbits by autologous thrombus reinfusion and normal saline injection,and the serum levels of cytokines(TNF-α,IL-1β,HGF)in the two groups were monitored by enzyme-linked immunosorbent assay.Results:The expression levels of serum inflamma­tory cytokines(TNF-α,IL-1β)increased in both groups of rabbits within 1-3 hours of the acute stage of embolism,but the expression levels of serum inflammatory cytokines in experimental group of rabbits with pulmonary embolism caused by thrombosis increased more obviously.There was no significant change in serum HGF of rabbits before and after embolization in group B.The serum HGF content of experimental rabbits at 1 h,3 h,12 h,24 h and 48 h after embolization was significantly higher than that before embolization.And in the acute stage of embolism(1-12 hours),it showed a gradual upward trend.Conclusions:The expression level of serum growth factor is different in different acute stages of pulmonary embolism.Detect­ing serum cytokines in rabbits with acute pulmonary embolism is of great reference significance for improving clinical diagnosis.

A machine learning model for diagnosing acute pulmonary embolism and comparison with Wells score,revised Geneva score,and Years algorithm

Background:Acute pulmonary embolism(APE)is a fatal cardiovascular disease,yet missed diagnosis and misdiagnosis often occur due to non-specific symptoms and signs.A simple,objective technique will help clinicians make a quick and precise diagnosis.In population studies,machine learning(ML)plays a critical role in characterizing cardiovascular risks,predicting outcomes,and identifying biomarkers.This work sought to develop an ML model for helping APE diagnosis and compare it against current clinical probability assessment models.Methods:This is a single-center retrospective study.Patients with suspected APE were continuously enrolled and randomly divided into two groups including training and testing sets.A total of 8 ML models,including random forest(RF),Naïve Bayes,decision tree,K-nearest neighbors,logistic regression,multi-layer perceptron,support vector machine,and gradient boosting decision tree were developed based on the training set to diagnose APE.Thereafter,the model with the best diagnostic performance was selected and evaluated against the current clinical assessment strategies,including the Wells score,revised Geneva score,and Years algorithm.Eventually,the ML model was internally validated to assess the diagnostic performance using receiver operating characteristic(ROC)analysis.Results:The ML models were constructed using eight clinical features,including D-dimer,cardiac troponin T(cTNT),arterial oxygen saturation,heart rate,chest pain,lower limb pain,hemoptysis,and chronic heart failure.Among eight ML models,the RF model achieved the best performance with the highest area under the curve(AUC)(AUC=0.774).Compared to the current clinical assessment strategies,the RF model outperformed the Wells score(P=0.030)and was not inferior to any other clinical probability assessment strategy.The AUC of the RF model for diagnosing APE onset in internal validation set was 0.726.Conclusions:Based on RF algorithm,a novel prediction model was finally constructed for APE diagnosis.When compared to the current clinical assessment strategies,the RF model achieved better diagnostic efficacy and accuracy.Therefore,the ML algorithm can be a useful tool in assisting with the diagnosis of APE.

Depression, anxiety and influencing factors in patients with acute pulmonary embolism

Background Psychological distress has been widely studied in many cardiovascular and pulmonary diseases, but the condition in acute pulmonary embolism （APE） is unknown. The purpose of this study was to investigate levels of depression and anxiety and their influencing factors in APE patients. Methods Sixty consecutive patients with APE were subjected to investigation of depression and anxiety by the Beck Depression Inventory and State-Trait Anxiety Inventory, and 60 community-based subjects were enrolled as controls. APE patients were stratified as high-risk, intermediate-risk and low-risk according to the disease severity. Scores of depression and anxiety were compared by statistical analysis using paired t tests between APE patients and controls, and by analysis of variance within the APE patients with the three risk stratification. Factors influencing depression and anxiety were evaluated. Results The mean age of the patients （38 males and 22 females） was （52＋12） years. APE patients displayed higher scores of depression （P=0.04） and anxiety （P=0.001） compared with controls. Patients in the high-risk group displayed higher scores of depression （P=0.004） and anxiety （P=0.001） compared with those in the intermediate- and low-risk groups. Depression scores were highly correlated with anxiety scores （r=0.60, P 〈0.001）. Both depression and anxiety inversely related to risk stratification （P 〈0.01）, age （P 〈0.05）, and arterial blood oxygen pressure （PaO2） （P 〈0.05）. Linear regression analysis showed that PaO2 was independently inversely related to both depression （P 〈0.01） and anxiety （P 〈0.05）; risk stratification and age were independently inversely related to anxiety （P 〈0.05）. Conclusions Patients of APE suffered high levels of depression and anxiety, which were negatively influenced by PaO2 risk stratification and age.

Acute Pulmonary Embolism Caused by Local Resection of Choroidal Melanoma

Uveal melanoma is the most malignancy in adults, with 6-7 cases/million people.^-~j common primary ocular an annual incidence of The choroid is the most common site of involvement occurring in more than 90% patients.TM We conducted a retrospective study for uveal melanoma at Yongren Eye Center from 1997 to 201 I. A total of 682 cases of uveal melanoma were recorded. Among them, 176 （25.8%） cases received local resection surgery. Most of them survived after surgery and had good recovery. However, life-threatening complication of acute pulmonary embolism （APE） occurred in 3 choroidal melanoma patients shortly after surgery. Till now, to the best of our knowledge, there are few reports of severe postsurgical complications of choroidal melanoma.

Clinical and electrocardiographic characteristics of acute pulmonary embolism with ST elevation in the right precordial leads

Background ST-segment elevation （STE） in the right precordial leads is an ECG manifestation of acute pul- monary embolism （APE） and some patients present with concomitant STE in the inferior leads. This clinical enti- ty apparently deserves careful attention. Methods We included 42 APE patients presenting with i〉 0.1 mV STE in leads V1-V3/V4. Clinical and ECG characteristics in 15 patients with and 27 without STE in the inferior leads were included for comparison. Results Of the 42 patients, 98% were classified as high or intermediate risk patients, 79% showed ECG signs of right ventricular strain （RVS） and 83% showed the maximal amplitude of STE in leads V1-V2. The patients with STE in the inferior leads presented with faster heart rate （131±30 vs. 108_＋21 beats/min, P=0.015）, lower systolic blood pressure （107±22 vs. 123_＋26 mmHg, P=0.043）, higher incidence of ele- vated troponin （87% vs. 56%, P=0.040） and need to intensify therapy （73% vs. 33%, P=0.013）. Conclusions STE in the right precordial leads is an ECG manifestation of intermediate to high risk in APE patients. The ECG characteristics include the maximal amplitude of STE in leads V1-V2 and the RVS pattern. Simultaneous STE in the inferior and right precordial leads is associated with hemodynamic instability and need for intensified therapy.

Electrocardiographic differentiation between acute coronary syndrome and acute pulmonary embolism associated with inverted T waves in precordial leads

Background Inverted T waves in precordial leads are often seen in patients with acute pulmonary embolism （APE） and acute coronary syndrome （ACS）. The purpose of this study was to analyze the electrocardiogram （ECG） difference between APE and ACS related inverted T waves in precordial leads. Methods The ECG difference among 62 patients with APE and 125 patients with ACS related inverted T waves in precordial leads were compared. Results Compared with ACS, Patients with APE were more frequently associated with incomplete or complete RBBB or slurred S wave in lead V1, the sum of the depth of inverted T waves in leads V1 and V2 not less than in lead V3 and V4 （inverted TV1 ＋ V2 ≥ inverted TV3 ＋ V4）, and inverted T waves in leads V1 and Ⅲ. Conclusions Complete or incomplete RBBB or slurred S wave in lead V1, inverted T waves in leads V1 and III, and inverted TV1 ＋ V2 ≥ inverted TV3 ＋ V4 are useful criteria for predicting APE.

Acute pulmonary embolism immediately after cesarean section despite dilatation of the left ventricle:a case report and literature review

Introduction Pulmonary embolism is a lethal complication during pregnancy and the puerperium.Compared with vaginal delivery,the risk of pulmonary disease is almost twice as high with cesarean section.However,diagnosing a pulmonary embolism can be challenging.Case presentation A 31-year-old nulliparous woman underwent cesarean section.Postoperatively,the patient suddenly developed dyspnea and dull pain in the left back region and cardiopulmonary function deteriorated rapidly.Venous ultrasonography confirmed thrombosis of the left common iliac vein.Transthoracic echocardiography revealed a normal right heart and a dilated left ventricle with a patent foramen ovale.An acute pulmonary embolism was confirmed by pulmonary angiography.Catheter-directed thrombus fragmentation and thrombolysis were then performed.Conclusion Dilated left ventricular echocardiography does not exclude postpartum acute pulmonary embolism.In extreme emergencies,when acute pulmonary embolism is the most likely diagnosis and life-threatening,catheter-directed angiography may be preferred over other approaches.

Risk factors for pulmonary embolism in acute exacerbation of chronic obstructive pulmonary disease

Objective To study the risk factors for acute pulmonary embolism(PE)in patients with acute exacerbationof chronic obstructive pulmonary disease(AECOPD).Methods From November 2009 to May 2014,522 patients[aged 42-93 years,mean(72±9)]with AECOPD received CT pulmonary angiography(CTPA)in

Correlation of D-dimer level with the radiological severity indexes of pulmonary embolism on computed tomography pulmonary angiography

Background It is known that the main role of D-dimer has been as an exclusionary test in patients with suspected venous thromboembolism.However,the D-dimer is increasingly beginning to find clinical utility as a marker in the evaluation of the extent of the embolic disease.The aim of the study was to determine whether D-dimer levels predict the radiological markers of pulmonary embolism （PE） severity using Mastora score.Methods This prospective study involved 69 patients with acute PE proved by computed tomography pulmonary angiography （CTPA）.The D-dimer level was noted.A pulmonary artery obstruction index （PAOI; Mastora score） ≥21.3% indicated severe obstruction of PE.A right ventricle/left ventricle （RV/LV） ratio 〉0.9 indicated RV dysfunction.Results The median D-dimer level and PAOI were 765 μg/L （95% C/：750-1 205 μg/L） and 16.77% （95% CI：16.32%-23.06%）,respectively.The D-dimer level was positively correlated with PAOI （r=0.417,P 〈0.000 1）.PAOI ≥21.3% was associated with high D-dimer levels （median,993 μg/L （95% C/：856-1 841 μg/L）,Z=-2.991,P=0.003）.The D-dimer level was correlated with the RV/LV ratio （r=0.272,P=0.024）.RV/LV ratios 〉0.9 were associated with high D-dimer levels （median,880 μg/L （95% CI：764-1 360 μg/L）,Z=-2.070,P=0.038）.PAOI was positively correlated with the RV/LV ratio （r =0.390,P=0.001）.After three months,both the PAOI and D-dimer levels decreased （Z=-7.009,P 〈0.000 1; Z=-6.976,P〈0.000 1,respectively）.Conclusion D-dimer levels are positively correlated with PE burden and right ventricle dysfunction on CTPA,and can help monitor the therapeutic response.

Understanding COVID-19-associated coagulopathy:From PIC to SIC or DIC

Coagulopathy,characterized by a high D-dimer level,is a common pathological occurrence in coronavirus dis-ease 2019(COVID-19)and is associated with poor prognosis.Severe cases with COVID-19 is associated with a significantly higher risk of deep vein thrombosis and acute pulmonary embolism.Pulmonary intravascular coagulopathy is the characteristic coagulopathy in COVID-19.Unlike sepsis-induced coagulopathy and dissem-inated intravascular coagulation,which are manifestations of systemic coagulopathy,pulmonary intravascular coagulopathy is a manifestation of a local coagulation disorder in the lung.The progression from pulmonary intravascular coagulopathy to sepsis-induced coagulopathy or disseminated intravascular coagulation in the con-text of COVID-19 may indicate that the patient’s coagulation dysfunction has progressed from local to systemic.Exploring the associated coagulation disease will aid in the understanding of the pathophysiological mechanisms underlying severe COVID-19.