Advanced management of intermediate-high risk pulmonary embolism

This article is one of ten reviews selected from the Annual Update in Intensive Care and Emergency Medicine 2021. Other selected articles can be found online at https://www.biomedcentral.com/collections/annualupdate2021 . Further information about the Annual Update in Intensive Care and Emergency Medicine is available from https://link.springer.com/bookseries/8901 .

Institutional Experience With Venoarterial Extracorporeal Membrane Oxygenation for Massive Pulmonary Embolism: A Retrospective Case Series

OBJECTIVE

Despite advances in treatment, massive pulmonary embolism (PE) remains associated with significant morbidity and mortality. The role of venoarterial extracorporeal membrane oxygenation (VA ECMO) in the setting of massive PE is evolving and includes potential roles both in initial management and as a rescue strategy.

DESIGN

Single-center case series that reported demographics and outcomes for patients with massive PE who underwent VA ECMO.

SETTING

This investigation was performed at a quaternary referral center with several hospitals throughout the greater Atlanta, GA, area.

PARTICIPANTS

The study comprised adult patients (age ≥18 y) admitted to the authors' hospital system. Patients were identified using an internal registry of ECMO patients that contains basic demographic information (age, weight, treatment dates and times, ECMO configuration) and primary diagnosis.

INTERVENTIONS

No interventions were performed.

MEASUREMENTS AND MAIN RESULTS

Seventeen patients who met the inclusion criteria were identified, with 16 patients cannulated peripherally and one patient cannulated centrally for VA ECMO. Survival to hospital discharge was 80% for patients who underwent VA ECMO as an initial approach versus 42% for those in whom it was used as a rescue modality.

CONCLUSIONS

The results suggested that patients placed on VA ECMO earlier during their course of massive PE may have improved mortality. Additional investigation is needed to clarify the optimal sequence and timing of therapies surrounding the initiation of VA ECMO in patients with massive PE.

Psoas Muscle Area Measured with Computed Tomography at Admission to Intensive Care Unit: Prediction of In-Hospital Mortality in Patients with Pulmonary Embolism

Aim

Sarcopenia, a core component of physical frailty, is an independent risk factor for suboptimal health outcomes in hospitalized patients, especially in the intensive care patients. Psoas muscle areas can be assessed to identify sarcopenia. The aim of this study was to determine the prognostic value of psoas muscle area measured with CT for the prediction of in-hospital mortality in patients with pulmonary embolism at admission to the intensive care unit.

Methods

Patients with an admission abdominal computed tomography scan and requiring intensive care unit (ICU) stay were reviewed. Selected clinical data of patients admitted to intensive care unit for the management of pulmonary embolism were collected. Using CT scan images at the level of L3 vertebra, the psoas muscle area value was obtained by dividing the sum of the right and left psoas muscle areas into the body surface area.

Results

In-hospital mortality rate was 22.5% in 89 patients. The pulmonary embolism patients with in-hospital mortality had higher PESI and lower value of psoas muscle area, in addition to the lower systolic blood pressure and arterial oxygen saturation at admission. The increase in the value of psoas muscle area is associated with a decrease in the rate of in-hospital mortality. In patients with in-hospital mortality related to pulmonary embolism, the higher PESI and the lower value of psoas muscle area were considered in accordance with the outcome of patients.

Conclusions

For the prediction of in-hospital mortality risk in patients with pulmonary embolism managed in intensive care unit, the psoas muscle area value has a merit to be used among the routine diagnostic procedures after further studies conducted with different severity of pulmonary embolism.