阿替普酶治疗急性肺栓塞高危患者29例疗效观察

目的探讨阿替普酶溶栓治疗急性肺栓塞高危患者的效果及安全性。方法 29例急性肺栓塞患者均应用阿替普酶进行溶栓治疗,溶栓后24h行CT肺动脉造影评定疗效,行超声心动图检查观察溶栓前、后右心室舒张末期前后径（anterior-posterior diameter,APD）、右心室舒张末期横径（transverse diameter,TD）、肺动脉压（pulmonary arterial pressure,PAP）、三尖瓣反流压差（tricuspid valve pressure gradient,TRPG）、右心室壁运动幅度（right ventricular wall motion amplitude,RVAWM）,检测溶栓前、后D-二聚体、B型脑钠肽（（brain natriuretic peptide,BNP）水平,记录溶栓后不良反应发生情况。结果本组有效率为93.1%;溶栓后APD、TD、PAP、TRPG较溶栓前下降,RVAWM较溶栓前增加（P〈0.05）;D-二聚体、BNP水平较治疗前下降（P〈0.05）;溶栓后出血4例,死亡1例。结论阿替普酶适用于急性肺栓塞高危患者的快速溶栓治疗。     

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.     

Treatment of acute pulmonary embolism by a low molecular weight heparin fraction. A preliminary study

We evaluated the antithrombotic efficacy of the low molecular weight heparin (LMWH) fraction PK 10169 in nine consecutive patients with acute pulmonary embolism documented by pulmonary angioscan and angiography. Therapy with PK 10169 was initiated by an i.v. bolus of 0.5 mg/kg, followed by a continuous intravenous infusion during the first 10 days; the drug was then given subcutaneously twice daily during the following 15 days. The dosage of PK 10169 was adjusted by daily measurements of anti-Xa and anti-IIa activities using amidolytic methods. For a dosage ranging from 1.4 to 4.1 mg/kg per day during the i.v. period and from 0.7 to 3.5 mg/kg per day during the s.c. period, the anti-Xa activity ranged from 4 to 8.7 PK U/ml and from 4.5 to 7.2 PK U/ml respectively. Clinical improvement was observed in all the patients and was consistent with progressive reperfusion evaluated by successive angioscans. No recurrence of pulmonary embolism occurred. No deleterious hemorrhagic side-effects were observed, even in two patients at high risk of bleeding. In this pilot study, the LMWH fraction PK 10169 proved to be an effective anticoagulant therapy during the first three weeks after pulmonary embolism in man.     

Use of bivalirudin for heparin-induced thrombocytopaenia after thrombolysis in massive pulmonary embolism: a case report

A 68-year-old man was referred to the emergency department 6 h after onset of sudden acute dyspnoea. Immediate ECG showed sinus tachycardia with the typical S1-Q3-T3 pattern and incomplete right bundle branch block. The echocardiogram showed the presence of mobile thrombus in the right atrium, a distended right ventricle with free wall hypokinesia and displacement of the interventricular septum towards the left ventricle. Lung spiral computed tomography (CT) showed bilateral pulmonary involvement and confirmed the picture of a thrombotic system in the right atrium and caval vein. Thrombolytic treatment with recombinant tissue plasminogen activator (rt-PA) and heparin (alteplase 10 mg bolus, then 90 mg over 2 h) was administered. Six hours after thrombolysis bleeding gums and significant reduction in platelet count (around 50,000) were observed. Heparin was discontinued and bivalirudin (0.1 mg/kg bolus and 1.75 mg/kg per h infusion) plus warfarin was initiated and continued for 5 days until the international normalised ratio (INR) was within the therapeutic range (2.0–3.0) for 2 consecutive days, with concomitant platelet count normalisation. Lung spiral and lower abdominal CT before discharge did not show the presence of clots in the pulmonary arteries of the right and left lung. This case suggests that bivalirudin could offer promise for use in patients with heparin-induced thrombocytopaenia (HIT) after thrombolysis for massive pulmonary embolism.     

PaCO(2)/ETCO(2) gradient: early indicator of thrombolysis efficacy in a massive pulmonary embolism

End tidal CO(2) measurement may be helpful in detecting the efficacy of thrombolysis after a massive pulmonary embolism. We report the case of a 76-year-old man with a massive pulmonary embolism, who required early intubation and mechanical ventilation. Thrombolysis with rtpA (total dosage: 60 mg) was initiated. During this procedure, clinical data, arterial blood gases and end-tidal CO(2) with a capnograph were recorded. Before thrombolysis the P(a-ET)CO(2) gradient was raised to 25 mmHg. During thrombolysis, the clinical data improved and the P(a-ET) gradient fell to 14 mmHg. We postulate that the P(a-ET)CO(2) gradient seems to be a reasonable indicator of efficacy of thrombolysis in this setting. However, the gradient did not return to normal values (4-5 mmHg). The possible reasons for this may be that during mechanical ventilation there was a large ventilation-perfusion ratio and the cardiac output may have still reduced. With these limitations, we conclude that the P(a-ET)CO(2) gradient should be evaluated as an indicator of pulmonary reperfusion in massive pulmonary embolism.     

Endoscopic injection treatment in patients with shock and gastrointestinal bleeding or stigmata of recent hemorrhage

Forty cases of upper gastrointestinal bleeding were studied. Twenty-three patients had shock and active bleeding (3 spurting, 12 oozing and 2 a clot with oozing) or stigmata of recent hemorrhage (4 with a clot and 2 with a visible vessel). Nineteen of these were submitted to endoscopic injection. In 4 cases with multiple acute hemorrhagic lesions and shock, and in 17 patients with stigmata of recent bleeding without shock, the technique was not carried out. None of the patients had a rebleed. One patient was submitted to surgery 24 hours after injection for a large acute gastric ulcer in the process of perforating, and died of pulmonary embolism 4 days later. No technique-related complications were observed. We believe endoscopic injection treatment might be the technique of choice in patients with shock and active bleeding or stigmata of recent hemorrhage of the upper gastrointestinal tract.     

Histopathological studies on kidneys from patients treated with large amounts of blood preserved with ACD-adenine

Kidneys from six patients who died soon after open-heart surgery have been examined. During and after surgery the patients were transfused with ACD-adenine blood. There were no DOA crystals in the kidneys from five patients who received 13–30 units of blood, corresponding to 8.7-15.1 mg adenine per kg body weight, and who died within 12 hours after surgery. The sixth patient had an extremely massive transfusion of 118 units (95 mg adenine/kg body weight) administered during 5 days. He died from hemorrhagic shock on the seventh day. He had an impaired renal function and in his kidneys there was a moderate number of birefringent, rosette-shaped crystals. The use of ACD-adenine blood is discussed.     

Cerebral infarction following thrombolysis for massive pulmonary embolism

A 29-year-old male developed a fatal stroke 6 h after successful thrombolysis for massive pulmonary embolism. Autopsy showed thrombus protruding through a patent foramen ovale (PFO). A strand of thrombus extended from the aortic arch into the left common carotid artery. The brain showed extensive infarction of the left fronto-parietal area. Thrombolysis caused initial disintegration of the embolism. It is likely that thrombolysis caused fragments of clot to later break lose and embolise into the cerebral circulation. We discuss the need for risk stratification in patients who present with massive pulmonary embolism and PFO.     

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.     

DADLE模拟冬眠对休克大鼠血流动力学的影响

目的：探讨DADLE（冬眠诱导触发物类似物）对失血性休克大鼠血压和心功能的影响。方法：36只健康雄性SD大鼠,随机分成假手术对照组、休克对照组和DADLE实验组（分成1mg/kg组和5mg/kg组）,制成失血性休克大鼠模型,监测复苏后3小时内各时点动脉血压（MAP）和心功能指标（±dp/dtmax）。结果：DADLE实验组（包括1mg/kg组和5mg/kg组）复苏后5分钟MAP和±dp/dtmax开始升高,30分钟达高峰,复苏后同一时点各项指标均显著高于休克对照组（P〈0.05）,其中1mg/kg组和5mg/kg组没有显著差异。结论：DADLE能改善失血性休克大鼠的血压和心功能。     

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.     

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.     

Catheter intervention for pulmonary embolism

Thrombolysis is generally accepted in patients with acute massive pulmonary embolism, however, thrombolytic agents could not be fully administrated for cases with a high risk of bleeding. On the other hand, catheter intervention is an optimal treatment for massive pulmonary embolism patients having contraindications for thrombolysis, and is a minimally invasive alternative to surgical embolectomy. It can be performed with a minimum dose of thrombolytic agents or without, and can be combined various procedures including catheter fragmentation or embolectomy in accordance with the extent of thrombus on pulmonary angiogram. Hybrid catheter intervention for massive pulmonary embolism can reduce rapidly heart rate and pulmonary artery pressure, and can improve the gas exchange indices and outcomes.     

超声心动图急性肺栓塞溶栓治疗的评估

目的应用超声心动图技术观察急性肺栓塞患者溶栓抗凝治疗前后肺动脉栓子、右心结构及收缩功能的改变。方法前瞻性非随机对照研究,对2002年12月至2006年4月间经肺动脉CT或肺血管造影证实的30例急性肺栓塞患者行溶栓治疗,应用经胸超声心动图观察治疗前、治疗后24～30h、1个月的肺动脉栓子、主肺动脉及其分支内径、右房室内径,右室前壁运动幅度、右室舒张末期容积、右室射血分数,三尖瓣返流、肺动脉收缩压等指标。结果30例急性肺动脉栓塞患者溶栓治疗24～30h后右房室结构明显改善,表现为右房长径及横径、右室前后径及横径、主肺及右肺动脉内径、右室舒张末期容积与治疗前比较明显回缩(P<0.01),右室前壁运动幅度、右室射血分数有所增加(P<0.01),肺动脉收缩压明显下降(P<0.01);治疗后1个月后右房室大小、主肺及右肺动脉内径、右室舒张末期容积、右室前壁运动幅度及肺动脉收缩压等仍有恢复(P<0.05或P<0.01)。5例患者主肺动脉和/或右、左肺动脉内检出栓子,溶栓后栓子逐渐消失。结论超声心动图可动态、实时、无创评价急性肺动脉栓塞溶栓治疗效果,尤对血栓的溶解、右房室结构、右室超负荷及肺动脉高压的变化有独到的价值。     

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.     

介入溶栓治疗胸腔镜下肺癌根治术后高危肺栓塞的经验分析

目的 探讨不同介入溶栓方式治疗胸腔镜下肺癌根治术后高危肺栓塞(PE)的价值.方法 选取2018年就诊于河南大学第一附属医院的3例胸腔镜下肺癌根治术后发生高危PE的患者作为研究对象,其中1例接受单纯静脉溶栓治疗,1例接受单纯动脉介入溶栓治疗,1例接受静脉肺动脉联合介入溶栓治疗,分析3例患者住院治疗方式、溶栓治疗效果和术后...     

Glycine improves survival after hemorrhagic shock in the rat.

This study investigated the effect of glycine on hemorrhagic shock in the rat. Rats were bled to maintain mean arterial pressure at 30-35 mm Hg for 1 h and subsequently resuscitated with 60% shed blood and lactated Ringer's solution. Only 20% of rats receiving saline just prior to resuscitation survived 72 h after shock. Survival was increased by glycine (11.2-90.0 mg/kg, i.v.) in a dose-dependent manner (half-maximal effect = 25 mg/kg) and reached maximal values of 78% at 45 mg/kg. Eighteen hours after resuscitation, creatinine phosphokinase increased 23-fold, transaminases increased 33-fold, and creatinine was elevated 2.4-fold, indicating injury to the heart, liver, and kidney, respectively. Pulmonary edema, leukocyte infiltration, and hemorrhage were also observed. In the kidney, proximal tubular necrosis, leukocyte infiltration, and severe hemorrhage in the outer medullary area occurred in rats receiving saline. Glycine reduced these pathological alterations significantly. It has been reported that oxidative stress and tumor necrosis factor(TNF)-alpha-production are involved in the pathophysiology of multiple-organ injury after shock. In this study, free radical production was increased 4-fold during shock, an effect blocked largely by glycine. Increases in intracellular calcium and production of TNF-alpha by isolated Kupffer cells stimulated by endotoxin were elevated significantly by hemorrhagic shock, alterations which were totally prevented by glycine. Taken together, it is concluded that glycine reduces organ injury and mortality caused by hemorrhagic shock by preventing free radical production and TNF-alpha formation.     

Two cases of complications of the thrombolysis of right heart free-floating thrombi with pulmonary embolism: important role of echocardiographically based management

We present two cases where successful thrombolysis of right heart thrombi and pulmonary embolism was accompanied by serious adverse events. In patient 1 with massive pulmonary thromboembolism, transesophageal ultrasound revealed large right atrial thrombus entrapped in a patent foramen ovale. Initial treatment with heparin was substituted with thrombolysis, which resulted in clinical improvement and dissolution of right heart thrombus but was followed by fatal intracerebral haemorrhage. In patient 2, thrombolysis caused mobilisation of thrombotic mass as evidenced by disappearance of thrombus on ultrasound. Massive pulmonary thromboembolism resulted in circulatory collapse. Short cardiopulmonary resuscitation restored spontaneous circulation and the patient recovered completely.     

Intraosseous Administration of Thrombolytics for Pulmonary Embolism

Background

Massive pulmonary embolism is associated with cardiac dysfunction and ischemia, hemodynamic collapse, and significant potential for death. The American College of Chest Physicians and American College of Emergency Physicians each supports thrombolytic administration to hemodynamically unstable patients with acute pulmonary embolism.

Objectives

In the resuscitation of patients with massive pulmonary embolism and obstructive shock, difficulty with vascular access can hinder care. Alternative options may facilitate delivery of thrombolytics and enhance patient management.

Case Report

The case presented is a 36-year-old woman with massive pulmonary embolism associated with hemodynamic instability. She was treated with thrombolytics through a tibial intraosseous line.

Conclusions

To the best of our knowledge, this is the first identified case of a patient not in cardiac arrest in whom thrombolytics were administered via an intraosseous line. Similarly, we believe this is also the first reported case of thrombolytics delivered via an intraosseous line for massive pulmonary embolism in the United States.