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McGuire WC, Sullivan L, Odish MF, Desai B, Morris TA, Fernandes TM. Management Strategies for Acute Pulmonary Embolism in the ICU. Chest 2024:S0012-3692(24)00675-5. [PMID: 38830402 DOI: 10.1016/j.chest.2024.04.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2023] [Revised: 04/11/2024] [Accepted: 04/15/2024] [Indexed: 06/05/2024] Open
Abstract
TOPIC IMPORTANCE Acute pulmonary embolism (PE) is a common disease encountered by pulmonologists, cardiologists, and critical care physicians throughout the world. For patients with high-risk acute PE (defined by systemic hypotension) and intermediate high-risk acute PE (defined by the absence of systemic hypotension, but the presence of numerous other concerning clinical and imaging features), intensive care often is necessary. Initial management strategies should focus on optimization of right ventricle (RV) function while decisions about advanced interventions are being considered. REVIEW FINDINGS We reviewed the existing literature of various vasoactive agents, IV fluids and diuretics, and pulmonary vasodilators in both animal models and human trials of acute PE. We also reviewed the potential complications of endotracheal intubation and positive pressure ventilation in acute PE. Finally, we reviewed the data of venoarterial extracorporeal membrane oxygenation use in acute PE. The above interventions are discussed in the context of the underlying pathophysiologic features of acute RV failure in acute PE with corresponding illustrations. SUMMARY Norepinephrine is a reasonable first choice for hemodynamic support with vasopressin as an adjunct. IV loop diuretics may be useful if evidence of RV dysfunction or volume overload is present. Fluids should be given only if concern exists for hypovolemia and absence of RV dilatation. Supplemental oxygen administration should be considered even without hypoxemia. Positive pressure ventilation should be avoided if possible. Venoarterial extracorporeal membrane oxygenation cannulation should be implemented early if ongoing deterioration occurs despite these interventions.
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Affiliation(s)
- W Cameron McGuire
- Division of Pulmonary, Critical Care, Sleep Medicine, and Physiology, University of California, San Diego, La Jolla, CA.
| | - Lauren Sullivan
- Division of Pulmonary, Critical Care, Sleep Medicine, and Physiology, University of California, San Diego, La Jolla, CA
| | - Mazen F Odish
- Division of Pulmonary, Critical Care, Sleep Medicine, and Physiology, University of California, San Diego, La Jolla, CA
| | - Brinda Desai
- Division of Pulmonary, Critical Care, Sleep Medicine, and Physiology, University of California, San Diego, La Jolla, CA
| | - Timothy A Morris
- Division of Pulmonary, Critical Care, Sleep Medicine, and Physiology, University of California, San Diego, La Jolla, CA
| | - Timothy M Fernandes
- Division of Pulmonary, Critical Care, Sleep Medicine, and Physiology, University of California, San Diego, La Jolla, CA
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2
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Febra C, Santos AR, Cabrita I, Bento J, Pacheco J, Mendes M, Isidro M, Batista R, Macedo AMAFM. Comparison of diuretics and fluid expansion in the initial treatment of patients with normotensive acute pulmonary embolism: a systematic review and meta-analysis. Emerg Med J 2024; 41:187-192. [PMID: 38253364 DOI: 10.1136/emermed-2023-213525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 01/05/2024] [Indexed: 01/24/2024]
Abstract
BACKGROUND Right ventricular (RV) dysfunction is the main cause of death in patients with normotensive acute pulmonary embolism (PE). The optimal management for this subset of patients remains uncertain. This systematic review and meta-analysis focused on the comparison of diuretics and fluid expansion in patients with acute PE presenting with RV dysfunction and haemodynamic stability. METHODS A systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines considering only RTCs. The authors searched the traditional and grey literature through 1 November 2022. Meta-analysis used open source packages in R. Inverse variance fixed-effects models with OR as the effect measure were used for primary analyses. The main outcomes defined in this review protocol included pulmonary arterial systolic pressure (PASP), creatinine value changes and N-terminal pro-B-type natriuretic peptide during the first 24 hours. RESULTS Four studies with a total of 452 patients met the inclusion criteria. The baseline characteristics of patients were similar across all studies. Overall, patients receiving diuretics had a significant 24 hours reduction in pro-B-type natriuretic peptide (standard mean difference of -41.97; 95% CI -65.79 to -18.15), and PASP (standard mean difference of -5.96; 95% CI -8.06 to -3.86). This group had significantly higher creatinine levels (standard mean difference of 7.74; 95% CI 5.04 to 10.45). The quality of the studies was heterogeneous; two had a low risk of bias, and the other two had a high risk of bias. CONCLUSIONS Very few studies have compared the efficacy and safety of diuretics and fluid expansion in normotensive patients with acute PE with RV failure. Overall, furosemide appears to reduce RV dysfunction in this subset of patients compared with fluid expansion. Further research is required to confirm these findings.
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Affiliation(s)
- Cláudia Febra
- University of Porto, Porto, Portugal
- Department of Intensive Care, Hospital da Luz, Lisboa, Lisboa, Portugal
| | - Ana Rita Santos
- Faculdade de Medicina da Universidade do Algarve, Universidade do Algarve, Faro, Portugal
| | - Isabel Cabrita
- Faculdade de Medicina da Universidade do Algarve, Universidade do Algarve, Faro, Portugal
| | - Joana Bento
- Faculdade de Medicina da Universidade do Algarve, Universidade do Algarve, Faro, Portugal
| | - João Pacheco
- Faculdade de Medicina da Universidade do Algarve, Universidade do Algarve, Faro, Portugal
| | - Mariana Mendes
- Faculdade de Medicina da Universidade do Algarve, Universidade do Algarve, Faro, Portugal
| | - Michael Isidro
- Faculdade de Medicina da Universidade do Algarve, Universidade do Algarve, Faro, Portugal
| | - Rafael Batista
- Faculdade de Medicina da Universidade do Algarve, Universidade do Algarve, Faro, Portugal
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Bejjani A, Khairani CD, Piazza G. Right Ventricular Recovery: Early and Late Changes after Acute PE Diagnosis. Semin Thromb Hemost 2023; 49:797-808. [PMID: 35777420 DOI: 10.1055/s-0042-1750025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Right ventricular (RV) failure is a critical cause of morbidity and mortality in patients presenting with pulmonary embolism (PE). The presentation of RV failure is based on the combination of clinical findings, laboratory abnormalities, and imaging evidence. An improved understanding of the pathophysiology of RV dysfunction following PE has given rise to more accurate risk stratification and broader therapeutic approaches. A subset of patients with PE develop chronic RV dysfunction with or without pulmonary hypertension. In this review, we focus on the impact of PE on the RV and its implications for risk stratification, prognosis, acute management, and long-term therapy.
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Affiliation(s)
- Antoine Bejjani
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Candrika D Khairani
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Gregory Piazza
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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Petit M, Vieillard-Baron A. Ventricular interdependence in critically ill patients: from physiology to bedside. Front Physiol 2023; 14:1232340. [PMID: 37614759 PMCID: PMC10442576 DOI: 10.3389/fphys.2023.1232340] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 07/27/2023] [Indexed: 08/25/2023] Open
Abstract
The review focuses on the mechanism of ventricular interdependence, a frequently encountered phenomena, especially in critically ill patients. It is explained by the anatomy of the heart, with two ventricles sharing a common wall, the septum, and nested in an acutely inextensible envelope, the pericardium. In pathological situation, it results in abnormal movements of the interventricular septum driven by respiration, leading to abnormal filling of one or the other ventricle. Ventricular interdependence has several clinical applications and explains some situations of hemodynamic impairment, especially in situations of cardiac tamponade, severe acute asthma, right ventricular (RV) overload, or more simply, in case of positive pressure ventilation with underlying acute pulmonary hypertension. Ventricular interdependence can be monitored with pulmonary arterial catheter or echocardiography. Knowledge of this phenomena has very concrete clinical applications in the management of filling or in the prevention or treatment of RV overload.
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Affiliation(s)
- Matthieu Petit
- Medical Intensive Care Unit, Ambroise Paré Hospital, Assistance Publique–Hôpitaux de Paris, Boulogne-Billancourt, France
- Inserm, CESP, Paris-Saclay University, Université de Versailles Saint-Quentin-en-Yvelines, Villejuif, France
| | - Antoine Vieillard-Baron
- Medical Intensive Care Unit, Ambroise Paré Hospital, Assistance Publique–Hôpitaux de Paris, Boulogne-Billancourt, France
- Inserm, CESP, Paris-Saclay University, Université de Versailles Saint-Quentin-en-Yvelines, Villejuif, France
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5
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Sifuentes AA, Goldar G, Abdul-Aziz AA, Lee R, Shore S. Mechanical Circulatory Support and Critical Care Management of High-Risk Acute Pulmonary Embolism. Interv Cardiol Clin 2023; 12:323-338. [PMID: 37290837 PMCID: PMC11321065 DOI: 10.1016/j.iccl.2023.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Hemodynamically significant pulmonary embolism (PE) remains a widely prevalent, underdiagnosed condition associated with mortality rates as high as 30%. The main driver of poor outcomes is acute right ventricular failure that remains clinically challenging to diagnose and requires critical care management. Treatment of high-risk (or massive) acute PE has traditionally included systemic anticoagulation and thrombolysis. Mechanical circulatory support, including both percutaneous and surgical approaches, are emerging as treatment options for refractory shock due to acute right ventricular failure in the setting of high-risk acute pulmonary embolism.
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Affiliation(s)
- Aaron A Sifuentes
- University of Michigan Department of Internal Medicine, 1500 East Medical Center Drive, 3116 Taubman Center, SPC 5368, Ann Arbor, MI 48109-5368, USA
| | - Ghazaleh Goldar
- Cleveland Clinic Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, 9500 Euclid Avenue, Mail Code J3-4, Cleveland, OH 44195, USA
| | - Ahmad A Abdul-Aziz
- Inova Heart and Vascular Institute, 3300 Gallows Road, Critical Care Medicine, Falls Church, VA 22042, USA
| | - Ran Lee
- Cleveland Clinic Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, 9500 Euclid Avenue, Mail Code J3-4, Cleveland, OH 44195, USA
| | - Supriya Shore
- University of Michigan Department of Internal Medicine, 1500 East Medical Center Drive, 3116 Taubman Center, SPC 5368, Ann Arbor, MI 48109-5368, USA.
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Pérez-Nieto OR, Gómez-Oropeza I, Quintero-Leyra A, Kammar-García A, Zamarrón-López ÉI, Soto-Estrada M, Morgado-Villaseñor LA, Meza-Comparán HD. Hemodynamic and respiratory support in pulmonary embolism: a narrative review. Front Med (Lausanne) 2023; 10:1123793. [PMID: 37332759 PMCID: PMC10272848 DOI: 10.3389/fmed.2023.1123793] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Accepted: 05/19/2023] [Indexed: 06/20/2023] Open
Abstract
Pulmonary embolism is a common and potentially fatal disease, with a significant burden on health and survival. Right ventricular dysfunction and hemodynamic instability are considered two key determinants of mortality in pulmonary embolism, which can reach up to 65% in severe cases. Therefore, timely diagnosis and management are of paramount importance to ensure the best quality of care. However, hemodynamic and respiratory support, both major constituents of management in pulmonary embolism, associated with cardiogenic shock or cardiac arrest, have been given little attention in recent years, in favor of other novel advances such as systemic thrombolysis or direct oral anticoagulants. Moreover, it has been implied that current recommendations regarding this supportive care lack enough robustness, further complicating the problem. In this review, we critically discuss and summarize the current literature concerning the hemodynamic and respiratory support in pulmonary embolism, including fluid therapy, diuretics, pharmacological support with vasopressors, inotropes and vasodilators, oxygen therapy and ventilation, and mechanical circulatory support with veno-arterial extracorporeal membrane oxygenation and right ventricular assist devices, while also providing some insights into contemporary research gaps.
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Affiliation(s)
| | - Irene Gómez-Oropeza
- Department of Health Science, Universidad de las Américas Puebla, San Andrés Cholula, Puebla, Mexico
| | | | - Ashuin Kammar-García
- Dirección de Investigación, Instituto Nacional de Geriatría, Mexico City, Mexico
| | | | - Maximiliano Soto-Estrada
- Departamento de Emergencias, Hospital General de Zona 11 IMSS Delicias, Delicias, Chihuahua, Mexico
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Krečak I, Nižetić K, Čeko M, Skelin M, Lucijanić M. Higher estimated plasma volume status may be associated with an inferior survival in patients with pulmonary embolism. Int J Lab Hematol 2023; 45:e32-e35. [PMID: 36226329 DOI: 10.1111/ijlh.13982] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Accepted: 09/30/2022] [Indexed: 11/26/2022]
Affiliation(s)
- Ivan Krečak
- Department of Internal Medicine, General Hospital of Šibenik-Knin County, Šibenik, Croatia
- School of Medicine, University of Rijeka, Rijeka, Croatia
| | - Karla Nižetić
- Department of Internal Medicine, General Hospital of Šibenik-Knin County, Šibenik, Croatia
| | - Monika Čeko
- Department of Internal Medicine, General Hospital of Šibenik-Knin County, Šibenik, Croatia
| | - Marko Skelin
- School of Medicine, University of Rijeka, Rijeka, Croatia
- Pharmacy Department, General Hospital of Šibenik-Knin County, Šibenik, Croatia
| | - Marko Lucijanić
- Division of Hematology, University Hospital Dubrava, Zagreb, Croatia
- School of Medicine, University of Zagreb, Zagreb, Croatia
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Affiliation(s)
- Brian A Houston
- From the Department of Medicine, Division of Cardiology, Medical University of South Carolina, Charleston (B.A.H., R.J.T.); and the Department of Medicine, Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville (E.L.B.)
| | - Evan L Brittain
- From the Department of Medicine, Division of Cardiology, Medical University of South Carolina, Charleston (B.A.H., R.J.T.); and the Department of Medicine, Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville (E.L.B.)
| | - Ryan J Tedford
- From the Department of Medicine, Division of Cardiology, Medical University of South Carolina, Charleston (B.A.H., R.J.T.); and the Department of Medicine, Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville (E.L.B.)
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Pastré J, Sanchis-Borja M, Benlounes M. Risk stratification and treatment of pulmonary embolism with intermediate-risk of mortality. Curr Opin Pulm Med 2022; 28:375-383. [PMID: 35855562 DOI: 10.1097/mcp.0000000000000905] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Intermediate-risk pulmonary embolisms (PE) represent a heterogeneous group at the high end of hemodynamically stable patients, characterized by a higher mortality rate. This challenging population gathers many unsolved question regarding its therapeutic management. The purpose of this review is to provide an updated overview of the literature regarding further risk stratification and treatment options in this population. RECENT FINDINGS If anticoagulation represents the undisputed first line of treatment, some patients especially in the intermediate-high risk subgroup may necessitate or could benefit from therapeutic escalation with reperfusion therapies. This includes systemic thrombolysis (ST) or catheter-directed therapies (CDT). ST, despite its high efficacy, is not recommended in this population because of prohibitive bleeding complications. Therefore, reduced-dose ST appears to be a promising option and is actually under evaluation. CDT are percutaneous reperfusion techniques developed to acutely decrease pulmonary vascular obstruction with lower-dose or no thrombolytic agents and, thus, potentially improved safety compared to ST. SUMMARY Great progress has been made in the recent years providing a wide range of therapeutic options. Optimal selection of patients who could benefit from these treatments is the key and is based on clinical, biological and radiological parameters evaluating right ventricle function and allowing accurate risk stratification. Pulmonary Embolism Response Team represents an efficient modality for therapeutic management especially in the intermediate-high risk subgroup.
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Affiliation(s)
- Jean Pastré
- Service de Pneumologie et Soins Intensifs, Hôpital Européen Georges Pompidou, AP-HP
| | - Mateo Sanchis-Borja
- Service de Pneumologie et Soins Intensifs, Hôpital Européen Georges Pompidou, AP-HP
- Université Paris Cité, Paris, France
| | - Manil Benlounes
- Service de Pneumologie et Soins Intensifs, Hôpital Européen Georges Pompidou, AP-HP
- Université Paris Cité, Paris, France
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Ferrari E, Sartre B, Labbaoui M, Heme N, Asarisi F, Redjimi N, Fourrier E, Squara F, Bun S, Berkane N, Breittmayer JP, Doyen D, Moceri P. Diuretics Versus Volume Expansion in the Initial Management of Acute Intermediate High-Risk Pulmonary Embolism. Lung 2022; 200:179-185. [PMID: 35381867 DOI: 10.1007/s00408-022-00530-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Accepted: 03/20/2022] [Indexed: 11/26/2022]
Abstract
AIMS The very early management of pulmonary embolism (PE), a part from antithrombotic treatment, has been little studied. Our aim was to compare the effects of diuretic therapy (DT) versus volume expansion (VE) in patients hospitalized for PE with RV dysfunction. METHODS AND RESULTS We conducted a randomized open-label multicentric study including patients with intermediate high-risk PE. Patients were randomized between diuretics or saline infusion. The primary endpoint was time to troponin (Tp) normalization. Secondary endpoints were time to normalization of B-type natriuretic peptide (BNP), changes in echocardiographic RV function parameters and treatment tolerance. Sixty patients presenting intermediate high-risk PE were randomized. Thirty received DT and 30 VE. We noted no changes in Tp kinetics between the two groups. In contrast, faster normalization of BNP was obtained in the DT group: 56 [28-120] vs 108 [48-144] h: p = 0.05, with a shorter time to 50%-decrease from peak value 36 [24-48] vs 54 [41-67] h, p = 0.003 and a higher rate of patients with a lower BNP concentration within the first 12 h (42% vs 12% p < 0.001). RV echocardiographic parameters were unchanged between the groups. One dose 40 mg furosemide was well-tolerated and not associated with any serious adverse events. CONCLUSION In the acute management of intermediate high-risk PE, initial therapy including diuretic treatment is well-tolerated and safe. Although changes in Tp kinetics and echocardiographic RV dysfunction parameters did not differ, normalization of BNP is achieved more quickly in the DT group. This finding, which need to be confirmed in trials with clinical end points, may reflects a rapid improvement in RV function using one dose 40 mg furosemide. TRIAL REGISTRY Clinical Trial Registration NCT02531581.
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Affiliation(s)
- Emile Ferrari
- Cardiology Department, Centre Hospitalier Universitaire de Nice, 30, Avenue de la voie romaine, CS 51069, 06001, Nice Cedex 1, France.
| | - Benjamin Sartre
- Cardiology Department, Centre Hospitalier Universitaire de Nice, 30, Avenue de la voie romaine, CS 51069, 06001, Nice Cedex 1, France
| | - Mohamed Labbaoui
- Cardiology Department, Centre Hospitalier Universitaire de Nice, 30, Avenue de la voie romaine, CS 51069, 06001, Nice Cedex 1, France
| | - Nathan Heme
- Cardiology Department, Centre Hospitalier Universitaire de Nice, 30, Avenue de la voie romaine, CS 51069, 06001, Nice Cedex 1, France
| | - Florian Asarisi
- Cardiology Department, Centre Hospitalier Universitaire de Nice, 30, Avenue de la voie romaine, CS 51069, 06001, Nice Cedex 1, France
| | - Nassim Redjimi
- Cardiology Department, Centre Hospitalier Universitaire de Nice, 30, Avenue de la voie romaine, CS 51069, 06001, Nice Cedex 1, France
| | - Etienne Fourrier
- Cardiology Department, Centre Hospitalier Universitaire de Nice, 30, Avenue de la voie romaine, CS 51069, 06001, Nice Cedex 1, France
| | - Fabien Squara
- Cardiology Department, Centre Hospitalier Universitaire de Nice, 30, Avenue de la voie romaine, CS 51069, 06001, Nice Cedex 1, France
| | - Sithy Bun
- Cardiology Department, Centre Hospitalier Universitaire de Nice, 30, Avenue de la voie romaine, CS 51069, 06001, Nice Cedex 1, France
| | - Nathalie Berkane
- Cardiology Department, Centre Hospitalier de Cannes, Cannes, France
| | - Jean Philippe Breittmayer
- Cardiology Department, Centre Hospitalier Universitaire de Nice, 30, Avenue de la voie romaine, CS 51069, 06001, Nice Cedex 1, France
| | - Denis Doyen
- Medical Intensive Care Unit, Centre Hospitalier Universitaire de Nice, Nice, France
- UR2CA, Université Côte d'Azur, Nice, France
| | - Pamela Moceri
- Cardiology Department, Centre Hospitalier Universitaire de Nice, 30, Avenue de la voie romaine, CS 51069, 06001, Nice Cedex 1, France
- UR2CA, Université Côte d'Azur, Nice, France
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Piazza G. Off the beaten path: the need for innovation in medical therapy to improve outcomes in acute pulmonary embolism. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2022; 11:10-12. [PMID: 34725676 DOI: 10.1093/ehjacc/zuab100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Affiliation(s)
- Gregory Piazza
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St., Boston, MA 02115, USA
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