Pitfalls in the Diagnosis of Peri-Operative Acute Pulmonary Embolism: A Case Report

An 80 years-old man with hypertension, atrial fibrillation, and coronary artery occlusion disease presented for an elective right femur bipolar hip arthroplasty under general anesthesia. Preoperative transthoracic echocardiography (TTE) showed only preexisting regional wall motion abnormality. During the reversal of muscular relaxation following surgery, there was a sudden decrease in blood pressure associated with rapid ventricular response, which was successfully treated by cardioversion. No decrease in end-tidal carbon dioxide level was observed during the hypotensive episode. However, despite fluid and blood resuscitation and vasopressor treatment, there was a repeated hemodynamic collapse postoperatively. A portable TTE showed dilated right atrium and right ventricle (RV), D-shaped left ventricle, and septal wall motion abnormalities consistent with RV pressure overload (McConnell’s sign). Computed tomography pulmonary angiography revealed multifocal PE (pulmonary embolism). Anticoagulation therapy was continued to avoid PE recurrence. The patient discharged uneventfully 30 days later. Perioperative PE is a rare and perhaps dangerous circumstance that can be challenging to diagnose when it happens under anesthesia. The likelihood of PE should always be suspected at the time of perioperative hemodynamic collapse.