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Intraoperative point-of-care subcostal Inferior Vena Cava (IVC) imaging to detect embolism during hip arthroplasty: clinical image

These images and video were obtained using a low-frequency curvilinear probe, at the subcostal Inferior Vena Cava (IVC) view on a patient with poor functional reserve undergoing a Total Hip Arthroplasty under spinal anesthesia. Embolic material in-transit was initially identified after hip luxation with progression of severity culminating in an embolic storm during cementing (Fig. 1). The embolic phenomena preceded hemo-dynamic instability and an episode of cardiac arrest in pulseless electrical activity. Cardiopulmonary resuscitation was successful. Surgery finalized without further events once the patient was stabilized. Once fully recovered, the patient was discharged home within 72 hours. She provided written informed consent for publication.

Figure 1
IVC subcostal view before hip luxation and during cementing. L, Liver; IVC, Inferior Vena Cana.

Embolic events are common but mostly undiagnosed phenomena during hip and knee arthroplasties.11 Hagio K, Sugano N, Takashina M, et al. Embolic events during total hip arthroplasty. An echocardiographic study. J Arthroplasty. 2003;18:186-92. However, severe embolic episodes may lead to hemodynamic collapse. The etiology of these emboli is believed to be mixed with bone and soft tissue debris, thrombus, and cement.22 Moriyama M, Watanabe S, Hiraki T, et al. Relationship between intraoperative transesophageal echocardiography findings and perfusion lung scintigraphy results on first postoperative day. Br J Anaesth. 2005;94:607-12. The use of Transesophageal Echocardiography (TEE) is well-described in the literature to diagnose and quantify embolic events during arthroplasty.33 Bisignani G, Bisignani M, San Pasquale G, et al. Intraoperative embolism, and hip arthroplasty: intraoperative transesophageal echocardiographic study. J Cardiovasc Med. 2008;9:277-81. However, TEE is not readily available in non-cardiac operating rooms and may not be feasible to perform in patients under spinal anesthesia and mild sedation. We here report the use of the subcostal IVC view as less invasive and more widely available alternative to monitor for embolic phenomena in real time during orthopedic surgery. The early identification of severe embolic events can alert the anesthesiologist and assist in early resuscitation and hemodynamic support, as well as potentially guide surgical technique and timing to prevent further embolization.

Supplementary materials

Supplementary material associated with this article can be found in the online version at doi:10.1016/j.bjane.2023.02.007.

  • Funding
    Anahi Perlas receives academic support time from a Merit Award, Department of Anesthesiology and Pain Medicine, University of Toronto.

References

  • 1
    Hagio K, Sugano N, Takashina M, et al. Embolic events during total hip arthroplasty. An echocardiographic study. J Arthroplasty. 2003;18:186-92.
  • 2
    Moriyama M, Watanabe S, Hiraki T, et al. Relationship between intraoperative transesophageal echocardiography findings and perfusion lung scintigraphy results on first postoperative day. Br J Anaesth. 2005;94:607-12.
  • 3
    Bisignani G, Bisignani M, San Pasquale G, et al. Intraoperative embolism, and hip arthroplasty: intraoperative transesophageal echocardiographic study. J Cardiovasc Med. 2008;9:277-81.

Publication Dates

  • Publication in this collection
    21 Apr 2023
  • Date of issue
    May-Jun 2023

History

  • Received
    06 Feb 2023
  • Accepted
    28 Feb 2023
Sociedade Brasileira de Anestesiologia (SBA) Rua Professor Alfredo Gomes, 36, Botafogo , cep: 22251-080 - Rio de Janeiro - RJ / Brasil , tel: +55 (21) 97977-0024 - Rio de Janeiro - RJ - Brazil
E-mail: editor.bjan@sbahq.org