Propofol administration during catheter-directed interventions for intermediate-risk pulmonary embolism is associated with major adverse events

Intubation and Mechanical Ventilation in Patients with Acute Pulmonary Embolism: A Scoping Review

OBJECTIVES

High-risk acute pulmonary embolism (PE) is associated with significant mortality and may require emergency endotracheal intubation and mechanical ventilation. Intubation and ventilation are thought to exacerbate cardiorespiratory instability. Our purpose was to conduct a systematic literature review to identify studies investigating peri-intubation events in acute PE.

METHODS

A systematic search of Medline, Embase, Web of Science, Cumulative Index to Nursing and Allied Health Literature, and Cochrane Library was performed. Results were screened by two independent observers. Studies reporting on intubation and positive pressure ventilation in acute PE patients were included. The primary outcome was adverse events during the peri-intubation period. Data was synthesized and an assessment of risk of bias was conducted. The review was registered on PROSPERO (CRD42023444483).

RESULTS

4100 unique articles were screened. Three retrospective studies comprising 104 patients with acute PE met criteria and were included. Peri-intubation, hemodynamic collapse was observed in 19%-28% of cases. Patients with hemodynamic collapse exhibited higher rates of echocardiographic RV dysfunction.

CONCLUSIONS

Peri-intubation adverse events are common in patients with acute PE. Current evidence is limited and highlights the need for further research to optimize management of respiratory failure in acute PE and patient selection for intubation to improve patient outcomes.

Incidence of Adverse Effects of Propofol for Procedural Sedation/Anesthesia in the Pediatric Emergency Population: A Systematic Review and Meta-Analysis

BACKGROUND

To investigate the incidence of adverse effects of propofol among pediatric population for sedation or anesthesia.

METHODS

We performed Cochrane Library, PubMed, CNKI, VIP, and Wanfang databases to research relevant literature. We did sensitivity analysis to assess the incidence of adverse effects of propofol among pediatric population for sedation or anesthesia.

RESULTS

In 132 studies, eight RCTs were included in this analysis. The result showed that adverse events (bradypnea, hypotension, hypertension, and apnea) were significantly improved in the pediatric emergency population in the propofol group, but it had no effect on the incidence of cough attacks, desaturation, agitation, stridor, and laryngospasm. Furthermore, the subgroup analysis showed that those who received propofol for had decreased adverse effects compared with the patients who received ketamine treatment (SMD = 0.44, 95%CI = [0.28, 0.67], I 2 = 0%, and P = 0.0002), which demonstrated that propofol could decrease the incidence of adverse effects compared with ketamine and ketofol.

CONCLUSIONS

The study demonstrated that propofol may decrease the incidence of bradypnea, hypotension, hypertension, and apnea, but it had no effect on the incidence of cough attacks, desaturation, agitation, stridor, and laryngospasm. Furthermore, more large RCTs are needed to assess incidence of adverse effects of propofol among pediatric population.

Catheter Directed Interventions for pulmonary embolism: Institutional Trends over a Decade 2010-2019

OBJECTIVES

Catheter Directed Interventions (CDIs) are commonly performed for acute Pulmonary Embolism (PE). The evolving catheter types and treatment algorithms impact the utilization and outcomes of these interventions. This study aimed to investigate the changes in CDI practice and their impact on outcomes.

METHODS

Patients who underwent CDIs for PE between 2010 and 2019 at a single institution were identified from a prospectively maintained database. A PE team was launched in 2012, and in 2014 was established as an official Pulmonary Embolism Response Team (PERT). CDI annual usage trends and clinical failures were recorded. Clinical success was defined as physiologic improvement in the absence of major bleeding, perioperative stroke or other procedure-related adverse event, decompensation for sub-massive or persistent shock for massive PE, need for surgical thromboembolectomy or death. Major bleeding was defined as requiring a blood transfusion, a surgical intervention, or suffering from an intracranial hemorrhage.

RESULTS

372 patients received a CDI for acute PE during the study period: age 58.9±15.4 years, males 187 (50.3%), sub-massive PE 340 (91.4%). CDI showed a steep increase in the early PERT years, peaking in 2016 with a subsequent decline. Ultrasound-assisted thrombolysis was the predominant CDI technique peaking at 84% of all CDI in 2014. Suction thrombectomy utilization peaked at 15.2% of CDI in 2019. Mean alteplase dose with catheter thrombolysis techniques decreased from 26.8±12.5mg in 2013 to 13.9±7.5mg in 2019 (P<.001). Mean lysis time decreased from 17.2±8.3 hours in 2013 to 11.3±8.2 hours in 2019 (P<.001). Clinical success for the massive and the submassive PE cohorts was 58.1% and 91.2% respectively; the major bleed rate was 25.0% and 5.3%. There were two major clinical success peaks, one in 2015 mirroring our technical learning curve and one in 2019 mirroring our patient selection learning curve. The clinical success drop in 2018 was primarily derived from blood transfusions due to acute blood loss during suction thrombectomy.

CONCLUSIONS

CDIs for acute PE have rapidly evolved with high success rates. Multidisciplinary approaches amongst centers with appropriate expertise are advisable for the safe and successful implementation of catheter interventions.