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Intra-operative crises · Core06 / 21

Massive pulmonary embolism for catheter thrombectomy48-year-old woman, 112 kg, day 3 after L4–5 laminectomy

Massive pulmonary embolism: RV failure support, non-shockable arrest and thrombolysis

From memory: the diagnosis and the notes are hidden. Answer each question aloud, then press Show.

Know this first

  • Massive PE: systolic under 90 for 15 min or more, or needing a vasopressor.
  • Hypoxia, hypercarbia and acidosis raise PVR and load a failing RV.
  • RV support: noradrenaline 0.1–1 mcg/kg/min, vasopressin 0.01–0.05 units/min, milrinone 0.3–0.7 mcg/kg/min.
  • PE arrest: lysis, surgical or catheter embolectomy and ECLS are all reasonable.

The patient

48-year-old woman, 112 kg, day 3 after L4–5 laminectomy, for catheter-directed thrombectomy in the angiography suite. Sudden breathlessness this morning; CT shows saddle pulmonary embolism. Echo: dilated RV, flattened septum. Drugs: noradrenaline 0.08 mcg/kg/min, started in the emergency department. Vitals: BP 88/56 on noradrenaline, HR 122, SpO2 89% on 15 L/min, RR 30.

The examiner asks

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  1. Consider

    What are your concerns?

    Show the answerHide the answer
    • A 48-year-old, 112 kg, with massive PE 3 days after spinal surgery, for catheter thrombectomy. Patient
    • High-risk PE: she needs a vasopressor to keep systolic near 90, and her RV is failing. Disease
    • Systemic lysis 3 days after spine surgery risks bleeding, so the clot comes out by catheter.
    • Her RV is the target: hypoxia, hypercarbia and acidosis all worsen its afterload.
    • A remote angiography suite: I bring a senior, my drugs and airway kit with me. Surgery

  2. Plan

    How will you anaesthetise her?

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    • Avoid intubation if I can: local and light sedation, so she keeps breathing herself. (Disease)
    • Positive pressure raises her RV afterload and cuts venous return; that can tip her into collapse.
    • Sedation in tiny steps; over-sedation brings hypercarbia, which loads her RV further.
    • Arterial line first; noradrenaline 0.1–1 mcg/kg/min to keep the systemic pressure up.
    • Her RV is perfused mostly in diastole, so any systemic fall starts an ischaemic spiral.
    • Limited fluid: a swollen RV pushes the septum left and starves the LV.
    • ECMO team told before we start.

  3. Crisis

    As sedation deepens, BP falls to 64/38, HR 138, SpO2 82%. What do you do?

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    • RV failure triggered by sedation and rising CO2: sedation stops and I support her breathing gently. (Crisis)
    • Noradrenaline up, and vasopressin 0.01–0.05 units/min added, to restore her RV coronary pressure.
    • Milrinone 0.3–0.7 mcg/kg/min for RV contraction, with the pressors running.
    • Inhaled nitric oxide 10–40 ppm to lower her pulmonary pressure.
    • No fluid bolus into her dilated RV.
    • The radiologist removes clot now; that is the treatment.

  4. Crisis

    During intubation she arrests. The monitor shows a narrow rhythm at 50 with no pulse. What now?

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    • Adult arrest algorithm, non-shockable branch: PEA from her massive PE. Crisis
    • Compressions now; adrenaline 1 mg IV without delay, repeated each 3–5 minutes.
    • Her reversible cause is known: the clot in her pulmonary artery.
    • Branch for her: catheter or surgical embolectomy; lysis is reasonable now despite her spine.
    • VA-ECMO during CPR; it's reasonable in arrest from PE.
    • After lysis, CPR continues for at least 60–90 minutes.
    • After ROSC: ICU, RV support, and spinal surgeons told about her bleeding risk. After surgery

Fatal mistakes

  • Deep sedation without a vasopressor running.
  • Fluid loading her failing RV.
  • Standard induction doses as if her RV were normal.

Checked against: Diagnosis of Pulmonary Embolism: A Review of Evidence-Based Approaches (2024) · AHA guidelines: special circumstances of resuscitation (2025) · Miller 10e · Stoelting 8e · Barash 9e

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Same topic, another patient

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Another patient · Thoracic and vascular. Massive pulmonary embolism for surgical embolectomy. Same massive PE for surgical embolectomy with lysis barred, ECMO plan

Know this first

  • Unstable PE carries a mortality around 77%.
  • Arrest from PE is usually PEA or asystole.
  • Keep systemic pressure above pulmonary pressure with vasopressors.
  • In arrest from confirmed PE: lysis, embolectomy or ECLS are all reasonable.

The patient

46-year-old woman, 82 kg, 4 days after a Whipple's resection, for emergency surgical pulmonary embolectomy; thrombolysis is barred by her bleeding risk. Sudden breathlessness and collapse; CT shows a saddle embolus; echo: dilated RV with a flattened septum. On noradrenaline 0.15 mcg/kg/min. Vitals: BP 86/54, HR 126, SpO2 88% on 15 L, RR 32. Lactate 4.2 mmol/L.

The examiner asks

Answer aloud, then press Show.

  1. Consider

    What are your concerns?

    Show the answerHide the answer
    • A 46-year-old in shock from massive PE, 4 days after a Whipple's, for emergency embolectomy. Patient
    • Recent major surgery bars thrombolysis, so surgical embolectomy is her option. Surgery
    • Unstable PE carries a mortality around 77%. Disease
    • Her RV is failing against high afterload and relies on systemic pressure for its own flow.
    • Hypoxia, high CO2 and acidosis will push her PVR higher still.

  2. Prepare

    How do you prepare?

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    • Arterial line before induction and central access, under local. Disease
    • Cardiac surgeon in the room, prepped and draped before induction. Surgery
    • ECMO team present: ECLS is reasonable if she arrests. Crisis
    • Noradrenaline running; vasopressin 0.01–0.05 units/min ready, as it spares pulmonary pressure. Disease
    • Inhaled nitric oxide 10–40 ppm ready to unload her RV.
    • No fluid boluses: her RV is dilated and pushing the septum into the LV.

  3. Plan

    How will you induce her?

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    • Etomidate or ketamine, titrated in small doses, to avoid a fall in pressure. Disease
    • Noradrenaline increased first, keeping systemic pressure above pulmonary pressure.
    • Gentle ventilation at low airway pressures; switching to controlled ventilation strains her RV.
    • 100% oxygen and normal CO2, so her PVR doesn't climb.
    • ICU after, with anticoagulation agreed with the surgeons. After surgery

  4. Crisis

    Moments after induction her systolic drops to 40, then the pulse is lost; the ECG still shows sinus rhythm at 130. What is your management?

    Show the answerHide the answer
    • Adult arrest algorithm: PEA from massive PE; CPR now and the surgeon told to open. (Crisis)
    • Non-shockable: adrenaline 1 mg immediately, then every 3–5 minutes.
    • Her cause is known: VA-ECMO or immediate surgical embolectomy.
    • Lysis reconsidered: in arrest from confirmed PE, the bleeding risk is weighed again.
    • If she is lysed, CPR continues 60–90 minutes before stopping.
    • Other causes for her: hypoxia, a line-related pneumothorax, abdominal bleeding.

Fatal mistakes

  • Full-dose induction without vasopressor support.
  • Fluid loading her failing right ventricle.
  • No ECMO plan before induction.
  • Positive-pressure ventilation with high airway pressures.

Checked against: AHA guidelines: special circumstances of resuscitation (2025) · Stoelting 8e · Miller 10e

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