Bolus injection of thrombolytic agents during cardiopulmonary resuscitation for massive pulmonary embolism

Thrombolytic therapy has proved to be efficacious in the treatment of massive and fulminant pulmonary embolism (PE), but thrombolysis has been considered as contraindicated during cardiopulmonary resuscitation (CPR). This review on the administration of thrombolytic agents in patients who have suffered massive PE necessitating CPR summarises 14 anecdotal reports and three case series involving 34 patients. The case series revealed an overall initial survival rate of 55–100% following bolus administration of thrombolytic agents. In general, bleeding complications were managed conservatively. The establishment of the diagnosis may be feasible using echocardiography or bedside angiography during CPR. However, therapeutic measures should be taken without delay; the patient's history and the clinical picture may thus be the only diagnostic criteria. Even where myocardial infarction is misinterpreted as PE during CPR, bolus injection of a thrombolytic agent can be an appropriate therapeutic option. An alternative may be mechanical catheter fragmentation of the thrombus with subsequent local thrombolysis. Surgery may be restricted to hospitals with ready access to extracorporeal circulation. We conclude that early administration of thrombolytic agents during PE necessitating CPR may help to reduce mortality. We favour the administration of urokinase (2– to 3 000 000-U bolus) or rt-PA.     

Mechanical circulatory assist for pulmonary embolism

Optimal management of acute pulmonary embolism remains controversial, despite advances in thrombolytic therapy. Haemodynamic instability and, in particular, right ventricular dysfunction is associated with poor outcomes. Urgent surgical embolectomy has been the treatment of choice in this category of patients. We present two cases in which percutaneous cardiopulmonary support (PCPS) was used as an adjunct to thrombolytic therapy for progressive circulatory collapse secondary to massive acute pulmonary embolism. This experience suggests that PCPS may offer an attractive option for a condition which continues to carry significant morbidity and mortality.     

Fogarty导管取栓加动脉内直接灌注溶栓药物治疗急性动脉栓塞(附5例报告)

作者报告采用Fogarty导管取栓术加动脉内直接灌注溶栓药物治疗急性动脉栓塞5例,共10例次。经此新疗法治疗,5例均肢体保存,症状消失。治疗时各例发病分别为3天、2(1/2)天、15小时、3小时和5天,作者提出取栓加溶栓药物灌注治疗的适应证除取决于发病时间外,当时肢体末端有否坏疽也很重要。Fogarty导管可取除主要血管内血栓,灌注溶栓药物则可溶化细小血管和毛细血管内血栓,二者结合使疗效明显提高。     

Whole lung pulmonary angiography in the intensive care unit with two portable chest x-rays

Suspected massive pulmonary embolism requires urgent, accurate diagnosis. We describe a technique for pulmonary angiography in the ICU. Four patients admitted with suspected pulmonary embolism had fulminating cardiorespiratory failure with support requirements precluding transfer. Each patient had a flow-directed pulmonary angiography catheter inserted into the pulmonary artery. In two catheter positions, 25 ml of iopamidol 612 mg/ml was delivered from a portable angiographic injector at a flow of 20 ml/sec. A portable x-ray was taken immediately before completion of syringe excursion. Major central pulmonary emboli were seen in three patients and a negative angiogram was obtained on the fourth. Two of the three positive diagnoses were confirmed at pulmonary embolectomy. The negative diagnosis was confirmed at autopsy. Pulmonary angiography via a flow-directed catheter enabled precise and rapid diagnosis of pulmonary embolism in patients too ill to transfer for formal angiography.     

Massive pulmonary embolism

An otherwise healthy 48-year-old woman presented in respiratory extremis from massive pulmonary embolism and promptly arrested. She underwent open-chest cardiopulmonary resuscitation followed by portable partial cardiopulmonary bypass and embolectomy but could not be resuscitated. Massive pulmonary embolism is frequently a desperate situation, but aggressive therapy with thrombolysis or embolectomy (in patients with contraindications to thrombolysis) may be lifesaving.     

Successful thrombolysis after pulmonary embolectomy for persistent massive postoperative pulmonary embolism

Massive postoperative pulmonary embolism (PE) is associated with a poor prognosis in patients presenting with haemodynamic instability. Since recent surgery is a commonly accepted contraindication for thrombolytic therapy, pulmonary embolectomy is an appropriate therapeutic approach in these patients. If life-threatening symptoms of PE persist after pulmonary embolectomy, however, very few other therapeutic options are available. We report the successful use of locally administered low-dose thrombolysis 2 days after pulmonary embolectomy in a patient with postoperative PE and persistent severe hypoxaemia and pulmonary hypertension. During and after thrombolysis, no bleeding complications occurred. We conclude that low-dose thrombolysis for PE may be considered even in patients who have recently undergone major thoracic and abdominal surgery if embolectomy and continued intravenous heparin have failed to be successful and life-threatening symptoms of PE persist.     

Management of venous thromboembolism in the intensive care unit

Venous thromboembolism, manifested as either deep venous thrombosis or pulmonary embolism (PE), is a major cause of morbidity and mortality in patients admitted to the intensive care unit. Clinically, PE may present as massive thromboembolism associated with cardiogenic shock or may be asymptomatic, as may occur with anatomically small emboli without hemodynamic or respiratory compromise. The management of venous thromboembolism in the critically ill patient can be exceedingly complex. The main treatment objectives are the prevention of recurrent PE and, in case of hemodynamic compromise, definitive therapy for deep venous thrombosis or PE involving removal of thrombus. Prevention of recurrent PE is accomplished with anticoagulation and/or placement of an inferior vena cava filter. Definitive therapy involves thrombolysis and surgical or catheter embolectomy. Fluid and vasoactive therapy with norepinephrine may be indicated for refractory hypotension in patients with massive PE.     

Hemodynamics and differentiated CO transfer following fulminant lung embolism and pulmonary artery embolectomy and following recurrent lung embolism

Pulmonary embolectomy as an emergent surgical treatment after massive pulmonary embolism often is necessary in cardiogenic shock (CS) and even without previous diagnostic. If complete dissolution of the thromboembolus is possible or spreading of microemboli may occur is unknown. Therefore we studied 21 patients surgically treated by embolectomy, ten of these with consecutive cardiogenic shock (CS) and twelve patients after repetitive microembolism and cava-blocking. Besides lung-functional parameters for special CO-diffusion capacity (DLCO), differentiated in membrane (DM) and vascular (VC) component (Roughton and Forster), we measured mean pulmonary artery pressure (PAP) at rest and at exercise. Patients after repetitive embolism showed considerably more diminution of DLCO (-31%) than those after single massive embolic event (-15%) even concomitant by CS (-10%). Repetitive microembolism lowered VC by 21%. Slight decrease of DM was found after CS. Mean pulmonary artery pressure was elevated at rest (26 mm Hg) and exercise (33 mm Hg) after repetitive microembolism and normal after massive embolism or CS. Pulmonary embolectomy may prevent disturbances of DLCO or PAP even after CS. Damage of vascular integrity (VC) was found after microembolism. Pulmonary embolectomy seems to remove total embolic material and therefore seems to be optimal.     

Early intervention in massive pulmonary embolism. A guide to diagnosis and triage for the critical first hour

The diagnosis of massive pulmonary embolism should be considered expeditiously in all patients with unexplained hypotension, syncope, cardiac arrest, or hypoxemic respiratory failure. The presence of right ventricular overload on physical examination or electrocardiogram is an especially important clue. Depending on local expertise and the patient's stability, V/Q scanning, CT angiography, echocardiography, and right heart catheterization can be useful in establishing a diagnosis of pulmonary embolism. Supportive treatment includes oxygen, vasoactive medicines, and sometimes fluids. Although heparin is important in nearly all patients, 70% to 80% of patients also require an IVC filter, thrombolysis, or embolectomy.     

Effectiveness of end-tidal carbon dioxide tension for monitoring thrombolytic therapy in acute pulmonary embolism

OBJECTIVE: In acute massive pulmonary embolism with hemodynamic instability, monitoring of pulmonary artery pressure can be used to assess the efficacy of thrombolytic therapy. As a noninvasive alternative to pulmonary artery catheterization, we investigated the efficacy of continuous monitoring of end-tidal CO2 tension. DESIGN: In 12 patients with massive pulmonary embolism who required mechanical ventilation, mean pulmonary arterial pressure (MPAP) and end-tidal carbon dioxide tension (ETCO2) were registered continuously during thrombolytic therapy. PaCO2, cardiac index as estimated by thermodilution catheter and respiratory ratio of arterial oxygen tension and inhaled oxygen concentration (PaO2/FIO2) were determined every 60 mins. MEASUREMENTS AND MAIN RESULTS: Before thrombolysis, MPAP (34.5+/-9.8 mm Hg) and the difference between PaCO2 and ETCO2 (10.1+/-4.7 mm Hg) were markedly increased compared with normal values. Continuously monitored MPAP was related to ETCO2 for both all patients (r2 = .42; p < .001) and individually (mean r2 = .92; range, .79-.98; p < .001). In ten survivors, the mean cardiac index and PaO2/FIO2 increased during therapy from 1.7+/-0.4 to 2.8+/-0.6 L/min x m2 and 125+/-27 to 285+/-50 mm Hg (p < .01, respectively). In these patients, the difference between PaCO2 and ETCO2 decreased from 9.8+/-4.5 to 2.8+/-0.9 mm Hg (p < .001). Recurrent embolism was detected in two patients by sudden reduction of ETCO2. CONCLUSIONS: Analysis of ETCO2 allows monitoring of the efficacy of thrombolysis and may reflect recurrent embolism. Thus, on the basis of this small study, analysis of ETCO2 appears to be useful for noninvasive monitoring in mechanically ventilated patients with massive pulmonary embolism.     

下腔静脉滤器植入对治疗下肢深静脉恤栓的探讨

目的总结下腔静脉滤器（IVCF）植入后取栓及溶栓治疗在下肢深静脉血栓中的应用经验。方法分析14例经下肢深静脉造影证实下肢深静脉血栓形成（DVT）的病例资料,先行下腔静脉滤器植入,后在透视引导下用大腔导管取栓及溶栓导管局部溶栓治疗。结果下腔静脉滤器植人全部成功,取栓及溶栓治疗显效12例,有效2例,无肺动脉栓塞症（PTE）及严重出血发生,下肢症状消失。结论腔静脉滤器植入后取栓及溶栓治疗DVT,疗效显著。     

Endovascular interventions for acute pulmonary embolism

Massive pulmonary embolism (PE) is a highly lethal condition with clinical manifestations of hemodynamic instability, acute right ventricular (RV) failure, and cardiogenic shock. Submassive PE, as defined by RV failure or troponin elevation, can result in life-threatening sequelae if treatment is not initiated promptly. Current treatment paradigm in patients with massive PE mandates prompt risk stratification with aggressive therapeutic strategies. With the advent of endovascular technologies, various catheter-based thrombectomy and thrombolytic devices are available to treat patients with massive or submassive PE. In this article, a variety of endovascular treatment strategies for PE are analyzed. The authors' institutional experience with ultrasound-accelerated thrombolytic therapy as well as catheter-directed thrombolytic therapy in patients with acute massive PE during a recent 10-year period is discussed. Finally, clinical evidence on the utilization of catheter-based interventions in patients with massive and submassive PE is also analyzed.     

Hemorrhagic disorders associated with thrombolytic therapy

Thrombolytic treatment for AMI, acute ischemic stroke, and massive pulmonary embolism has shown significant benefit. Along with the potential increase in perfusion and decrease in cell death, however, comes potential complications. Bleeding is the most common complication associated with thrombolytic therapy regardless of the particular agent and can range from minor bleeding from an i.v. site to a life-threatening hemorrhage, such as GI bleeding. Expert assessment and management of patients who develop bleeding complications is critical to desired patient outcomes. Knowledge of the diagnosis for which a thrombolytic agent is used, pathophysiology, hemodynamic changes, and symptoms of complications associated with bleeding, all present a challenge to nurses. Research-based algorithms, protocols, or standardized treatment plans and a multidisciplinary approach to thrombolytic therapy provide the best opportunity for success, reducing the risk and enhancing early intervention of complications. Although thrombolytic therapy creates its own set of challenges, the alternative--failure to restore perfusion to the myocardium, brain, or pulmonary vasculature--presents both a different set of challenges and a dismal outcome.     

Advanced treatment strategies for acute pulmonary embolism, including thrombolysis and embolectomy

Summary.  The optimal treatment strategy for acute pulmonary embolism relies upon a multidisciplinary team that rapidly assesses available data, performs additional testing if necessary, weighs treatment options, and recommends an appropriate therapeutic plan to the patient and family. Round-the-clock availability is imperative. Centers that specialize in pulmonary embolism management offer a wide range of therapeutic options. Hospitals with more limited facilities should establish pulmonary embolism patient referral and transfer contingency plans that can be activated at a moment's notice. Management options include anticoagulation alone, thrombolysis plus anticoagulation, insertion of an inferior vena caval filter, catheter embolectomy, or surgical embolectomy. The decision-making process requires accurate risk stratification, which is comprised of several crucial components: clinical evaluation that includes history and physical examination, biomarker measurement especially of troponin, as well as assessment of right ventricular size and function based upon chest CT scanning and echocardiography. The 'old school' approach of declaring a benign prognosis based solely upon the presence of normal systemic arterial pressure can delay advanced therapy until after the onset of irreversible cardiogenic shock. We have now formulated a more contemporary, comprehensive, and multifaceted strategy to prognosticate. Our 'new approach' uses advanced treatment strategies in addition to anticoagulation for those pulmonary embolism patients deemed to be at high risk for a poor outcome.     

Deciding when hemodynamic monitoring is appropriate. How will the data affect your diagnostic or therapeutic approach?

Hemodynamic data can be used to differentiate a variety of cardiopulmonary disorders, including right ventricular dysfunction, massive pulmonary embolism, and precapillary pulmonary hypertension. In patients with acute pulmonary edema, low-output states, or shock, hemodynamic measurements can help guide therapy; they also provide a precise estimate of a patient's response to vasoactive or inotropic drugs. Consider a flotation catheter for patients with complicated MIs, critically ill patients with multiorgan or major organ dysfunction, and high-risk cardiac patients undergoing surgery.     

Monitoring mixed venous oxygen saturation in patients with obstructive shock after massive pulmonary embolism

BACKGROUND: Patients with massive pulmonary embolism and obstructive shock usually require hemodynamic stabilization and thrombolysis. Little is known about the optimal and proper use of volume infusion and vasoactive drugs, or about the titration of thrombolytic agents in patients with relative contraindication for such treatment. The aim of the study was to find the most rapidly changing hemodynamic variable to monitor and optimize the treatment of patients with obstructive shock following massive pulmonary embolism. PATIENTS AND METHODS: Ten consecutive patients hospitalized in the medical intensive care unit in the community General Hospital with obstructive shock following massive pulmonary embolism were included in the prospective observational study. Heart rate, systolic arterial pressure, central venous pressure, mean pulmonary-artery pressure, cardiac index, total pulmonary vascular-resistance index, mixed venous oxygen saturation, and urine output were measured on admission and at 1, 2, 3, 4, 8, 12, and 16 hours. Patients were treated with urokinase through the distal port of a pulmonary-artery catheter. RESULTS: At 1 hour, mixed venous oxygen saturation, systolic arterial pressure and cardiac index were higher than their admission values (31+/-10 vs. 49+/-12%, p<0.0001; 86+/-12 vs. 105+/-17 mmHg, p<0.01; 1.5+/-0.4 vs. 1.9+/-0.7 L/min/m2, p<0.05; respectively), whereas heart rate, central venous pressure, mean pulmonary-artery pressure and urine output remained unchanged. Total pulmonary vascular-resistance index was lower than at admission (29+/-10 vs. 21+/-12 mmHg/L/min/m2, p<0.05). The relative change of mixed venous oxygen saturation at hour 1 was higher than the relative changes of all other studied variables (p<0.05). Serum lactate on admission and at 12 hours correlated to mixed venous oxygen saturation (r=-0.855, p<0.001). CONCLUSION: In obstructive shock after massive pulmonary embolism, mixed venous oxygen saturation changes more rapidly than other standard hemodynamic variables.     

Thrombolytic therapy for massive pulmonary embolism in a patient with a known intracranial tumor

The objective was to describe and review the use of thrombolytic therapy in a patient with an intracranial tumor and massive pulmonary embolism. This is the first reported case of a patient with a known glioblastoma multiforme and massive pulmonary embolism who was successfully treated with alteplase. Pulmonary embolism was demonstrated by a ventilation-perfusion scan and transthoracic echocardiogram with repeat studies demonstrating resolution of the thromboembolism and reperfusion of pulmonary vasculature. A review of the literature revealed that the incidence of intracranial hemorrhage with thrombolysis is <3% and compares favorably with the much higher mortality rate of 25% to >/=50% in patients with hemodynamically unstable pulmonary emboli. The benefit of thrombolysis may outweigh the risks of intracranial hemorrhage in these patients, and careful consideration for its use in these patients is warranted.     

肢体动脉急性栓塞或血栓形成的临床处理

目的　探讨四肢动脉急性栓塞或血栓形成的治疗及如何减少并发症的发生。方法　总结 32例动脉栓塞及血栓形成的治疗经验。结果　 6例保守治疗 ,3例行截肢术 ,2 3例行动脉或人工血管切开、Fogarty导管取栓术。术后死亡 3例 ,截肢 5例。结论　尽早的治疗对此病的预后至关重要 ,正确的术中、术后处理明显减少并发症的发生     

Is thrombolytic therapy effective for pulmonary embolism?

Pulmonary embolism is a disorder that is associated with significant morbidity and mortality. Right-sided heart failure and recurrent pulmonary embolism are the main causes of death associated with pulmonary embolism in the first two weeks after the embolic event. Thrombolysis is a potentially lifesaving therapy when used in conjunction with standard anticoagulation. However, it has significant side effects and must therefore be used with caution. Indications for thrombolysis are not well defined and are thus controversial. The only current absolute indication is massive pulmonary embolism with hypotension. Other potential indications include right heart dysfunction, recurrent pulmonary embolism and the prevention of pulmonary hypertension. However, no evidence exists to show benefit of thrombolytic therapy over standard anticoagulation therapy for recurrent pulmonary embolism, mortality or chronic complications. Bleeding is the most common complication of thrombolysis and may be fatal.     

Endovascular treatment

Acute pulmonary thromboembolism is a common condition with non-specific findings, high mortality, and multiple therapeutic options. Death in patients with acute massive pulmonary thromboembolism is caused by sudden circulatory collapse as a consequence of obstructed pulmonary blood flow. Initial therapy must therefore be directed toward quickly restoring pulmonary circulation. In a number of cases, thrombolytic therapy may fail to achieve this therapeutic goal in time. Percutaneous catheter treatment may represent an additional option for high-risk patients. In this paper, different concepts of such treatment include pigtail catheter thrombectomy and embolus aspiration with PTCA guiding catheter are described.