Pulmonary embolism induced by evacuator during transurethral resection of the prostate

A 79-year-old man was scheduled to undergo transurethral resection of the hypertrophied prostate during general anesthesia. Anesthesia was maintained with sevoflurane 0.5-1.0% and nitrous oxide 50% in oxygen mixture. Immediately after using an evacuator to remove small resected pieces of the prostate, end-tidal carbon dioxide pressure (EtCO2) decreased suddenly from 31 mmHg to 18 mmHg. Concurrently, decreases in systolic blood pressure from 110 mmHg to 60 mmHg and oxygen saturation from 100% to 95%, and an increase in arterial-alveolar carbon dioxide tension difference (a-ADCO2) were observed. We initially suspected the onset of pulmonary thrombosis as the cause of these events, ventilated the patient's lungs with 100% oxygen and administered 5,000 units of heparine and vasopressors intravenously. However, transesophageal echocardiography done subsequently revealed the presence of strongly echogenic images compatible with the air in the left cardiac atrium and the contribution of the air to those events. The EtCO2, blood pressure, and oxygen saturation improved in about 20 minutes after the initial decrease of the EtCO2 had been detected. Thereafter, surgical procedure was done uneventfully. In routine anesthetic management of transurethral surgery, it should be considered that the sudden deterioration in vital signs may have been caused by evacuator used.