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

Corujo, Alejandro; Girón-Arango, Laura; Irizaga, Gonzalo; Perlas, Anahi

doi:10.1016/j.bjane.2023.02.007

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.¹ 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.² The use of Transesophageal Echocardiography (TEE) is well-described in the literature to diagnose and quantify embolic events during arthroplasty.³ 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

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial No Derivative License, which permits unrestricted non-commercial use, distribution, and reproduction in any medium provided the original work is properly cited and the work is not changed in any way.

[1] 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] 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] 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.