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Massive PE Intraoperative — FRCA Final MCQ

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HardTrauma & Emergency AnaesthesiaMassive PE IntraoperativeFRCA Final

A 50-year-old woman (ASA II) is undergoing robotic hysterectomy in steep Trendelenburg. After 3 hours, the surgeon requests conversion to open. On returning to supine, her ETCO2 drops from 5.0 to 2.5 kPa and blood pressure falls to 60/35 mmHg. Airway pressures are normal. What is the most likely cause?

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Correct answer: B — Massive pulmonary embolism

The sudden drop in ETCO2 with haemodynamic collapse on repositioning from steep Trendelenburg to supine is highly suspicious for massive PE. Risk factors include: prolonged steep Trendelenburg (venous stasis), pneumoperitoneum (reduced venous return), and immobility. The change in position may have dislodged a lower limb DVT. Normal airway pressures exclude pneumothorax. Management: 100% O2, IV fluid bolus, vasopressors, consider thrombolysis or surgical embolectomy if massive PE confirmed. CT PA is diagnostic if the patient is stable enough.

Reference: RCOA – 2023 – Robotic surgery anaesthesia; NICE – 2020 – NG158 VTE