Intraoperative Pulmonary Embolism

Sudden ↑PA pressure → RV failure → cardiovascular collapse. May be thrombus, fat (long-bone fracture, IM rod), gas (laparoscopy CO₂, sitting craniotomy), or amniotic.

Recognition

•Sudden ↓ETCO₂ + ↓SpO₂ + ↑CVP + tachycardia
•Hypotension, ECG changes (RBBB, S1Q3T3)
•Bedside TEE: dilated RV, septal flattening, McConnell's sign
•Air embolism: 'mill-wheel' murmur, sudden CV collapse

Steps

1
100% FiO₂; deepen anesthesia if hemodynamics permit
2
Hemodynamic support
Norepinephrine first-line (preserves SVR/PVR ratio). Add inotrope if RV failing.
3
Avoid LR/excessive volume
RV is already overloaded; further preload worsens septal shift.
4
Inhaled vasodilator
iNO 20–40 ppm or inhaled epoprostenol — selectively reduce PVR.
5
Anticoagulation (if no surgical contraindication)
Heparin bolus 80 U/kg + infusion.
6
Consider thrombolysis (TPA) if cardiac arrest + suspected PE
TPA 50 mg over 2 min during arrest.
7
VA-ECMO bridge to thrombectomy/lytics if available

Drugs + doses

Drug	Dose	Note
Heparin	80 U/kg IV bolus, then infusion to aPTT 60–80
Norepinephrine	0.05–1 mcg/kg/min
Epinephrine	0.02–0.5 mcg/kg/min if RV failure
Inhaled NO	20–40 ppm
Alteplase (TPA)	50 mg IV bolus during arrest

Pitfalls

!Volume loading the failing RV worsens it. Resist 'just give fluid'.
!Air embolism: head-down + left-lateral + aspirate from CVC may help.

Sources

ESC PE Guidelines 2019
AHA Scientific Statement 2011

Anatomy reference

Sourced reference images. 4 matches for "pulmonary artery right ventricle lung circulation".

Right_ventricle_interior,_circa_1749._Wellcome_L0000262

Wikimedia · CC BY 4.0

OpenStax · CC BY 4.0

OpenStax · CC BY 4.0

Right_auricle_and_ventricle_of_the_heart_Wellcome_L0061488

Wikimedia · CC BY 4.0

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Education only — not a substitute for facility protocols, MOC certification, or clinical judgment. Always follow your institutional crisis algorithm and confirm doses against current package inserts.