Advances in the diagnosis and treatment of acute pulmonary embolism

Evidence-based perioperative diagnosis and management of pulmonary embolism: A systematic review

Background

The diagnosis and treatment of pulmonary embolism have multi-modal approach based on specificity, sensitivity, availability of the machine, and associated risks of imaging modalities.

Aim

This review aimed to provide shreds of evidence that improve perioperative diagnosis and management of suspected pulmonary embolism.

Methods

The study was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline 2020. After a clear criteria has been established an electronic searching database was conducted using PubMed, Google Scholar, Cochrane library, and Cumulative Index of Nursing and Allied Health Literature (CINAHL), with Key search terms included:('pulmonary embolism' AND' anesthesia management ', 'anticoagulation' AND 'pulmonary embolism', 'thrombolysis 'AND 'pulmonary embolism', 'surgery' AND' pulmonary embolism'), were used to draw the evidence.The quality of literatures were categorized based on WHO 2011 level of evidence and degree of recommendation, in addition, the study is registered with research registry unique identifying number (UIN) of reviewregistry1318." and has high quality based on AMSTAR2 assessment criteria.

Results

A totally of 27 articles were included [guidelines (n = 3), Cochrane (=5), systemic reviews (n = 7), meta-analyses (=2), RCT (n = 4), cohort studies (n = 3), and cross-sectional study (n = 3) and illegible articles identified from searches of the electronic databases were imported into the ENDNOTE software version X7.1 and duplicates were removed.

Discussion

Currently divergent and contradictory approaches are implemented in diagnosis and management for patients suspected of pulmonary embolism.

Conclusion

All perioperative patients, especially trauma victims, prostate or orthopedic surgery, malignancy, immobility, and obesity; smokers; and oral contraceptive users, antipsychotic medications are at increased risk of venous thromboembolism and need special caution during surgery and anesthesia.

The role of lung ultrasound in COVID-19 disease

This statement summarises basic settings in lung ultrasonography and best practice recommendations for lung ultrasonography in COVID-19, representing the agreed consensus of experts from the Ultrasound Subcommittee of the European Society of Radiology (ESR). Standard lung settings and artefacts in lung ultrasonography are explained for education and training, equipment settings, documentation and self-protection.

Potential role of sympathetic activity on the pathogenesis of massive pulmonary embolism with circulatory shock in rabbits

BACKGROUND

We recently showed that intravenous sodium nitroprusside treatment (SNP) could relieve the pulmonary vasospasm of pulmonary embolism (PE) and non-pulmonary embolism (non-PE) regions in a rabbit massive pulmonary embolism (MPE) model associated with shock. The present study explored the potential role of cardiopulmonary sympathetic activity on the pathogenesis and the impact of vasodilators on cardiopulmonary sympathetic activity in this model.

METHODS

Rabbits were randomly divided into sham operation group (S group, n = 8), model group (M, equal volume of saline intravenously, n = 11), SNP group (3.5 μg/kg/min intravenously, n = 10) and diltiazem group (DLZ, 6.0 μg/kg/min intravenously, n = 10).

RESULTS

MPE resulted in reduced mean arterial pressure and increased mean pulmonary arterial pressure as well as reduced PaO2 in the M, SNP and DLZ groups. Tyrosine hydroxylase (TH), neuropeptide Y (NPY) and endothelin-1 (ET-1) expression levels were significantly increased, while nitric oxide (NO) levels were reduced in both PE and non-PE regions in the M group. Both SNP and DLZ decreased mean pulmonary arterial pressure, reversed shock status, downregulated the expression of TH, NPY and ET-1, and increased NO levels in PE and non-PE regions.

CONCLUSION

Present results indicate that upregulation of the sympathetic medium transmitters TH and NPY in whole lung tissues serves one of the pathological features of MPE. The vasodilators SNP and DLZ could relieve pulmonary vasospasm in both embolization and non-embolization regions and reverse circulatory shock, thereby indirectly downregulating the sympathetic activation of the whole lung tissues and breaking a vicious cycle related to sympathetic activation in this model.

Significant Reduction of Pulmonary Embolism in Orthopaedic Trauma Patients

OBJECTIVES

To report results of a protocol to lessen incidence of pulmonary embolism (PE) among orthopaedic trauma patients.

DESIGN

Retrospective review.

SETTING

Level 1 trauma center.

PATIENT/PARTICIPANTS

Orthopaedic trauma inpatients were included in the study.

INTERVENTION

On arrival, an orthopaedic trauma patient's PE risk is calculated using a previously developed tool. If possible, patients at high risk are given their first dose of enoxaparin before leaving the emergency room. If other injuries preclude enoxaparin, then chemoprophylaxis is held for 24 hours. Twenty-four hours after arrival, the patient's ability to receive enoxaparin is reassessed. If possible, enoxaparin is started, with dosing twice a day. If enoxaparin is still contraindicated, a removable inferior vena cava filter is placed. Adequacy of enoxaparin dosing is tested using anti-factor Xa assay, drawn 4 hours after the third dose of enoxaparin. If the anti-factor Xa result is less than 0.2 IU/mL, a removable inferior vena cava filter is placed. If the result is 0.2-0.5 IU/mL, enoxaparin dosing is continued. If greater than 0.5 IU/mL, the dose of enoxaparin is reduced.

OUTCOME MEASURE

The main outcome measure was rate of PE.

RESULTS

From September 1, 2015 to December 31, 2015, our hospital admitted 420 orthopaedic trauma patients. Fifty-one patients were classed as high risk for PE. In September through December 2015, 9 sustained PE, 1 of which was fatal. From September 1, 2016 to December 31, 2016, our hospital admitted 368 orthopaedic trauma patients with comparable age and Injury Severity Score to 2015. Forty patients were at high risk for PE, 1 sustained a nonfatal PE. PE incidence from September to December 2016 was significantly lower than in 2015 (P = 0.02). Overall, 26 patients managed under the new protocol had IVCFs placed, 21 had their filters removed, and 3 died with filters in place. There were no complications during filter placement or removal. One patient had hemorrhage felt to be attributable to enoxaparin.

CONCLUSIONS

Our protocol emphasizes more robust enoxaparin dosing, and more frequent use of IVCF, but only among those at high risk. We lessened the incidence of PE, with a low complication rate.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Short-term outcomes of pulmonary embolism: A National Perspective

BACKGROUND

Pulmonary embolism (PE) is associated with significant morbidity and mortality in hospitalized patients. Real time data on 90-day mortality, bleeding, and readmission is sparse.

METHODS

The study cohort was derived from the National Readmission Data (NRD) 2013 to 2014. PE was identified using International Classification of Diseases, ninth Revision (ICD-9-CM) code 415.11/3/9 in the primary diagnosis field. Any admission within 90 days of primary admission was considered a 90-day readmission. Readmission etiologies were identified by ICD-9 code in the primary diagnosis field. Co-primary outcomes were 90-day readmission and 90-day mortality.

RESULTS

We identified 260 614 patients with primary admission PE, 55 659 (21.36%) patients were readmitted within 90 days. Most of them were of old age (age ≥ 65 years: 49.04%) and females (52.78%). Among the etiologies of readmission pulmonary disorders (22.94%) (Including recurrent PE 7.33%), malignancies (8.31%), and bleeding disorders (6.75%) were the most important causes of 90-day readmissions. On multivariate analysis, higher readmission rates and 90 days mortality were seen in patients with heart failure, chronic pulmonary disease, Anemia, malignancy, and with higher Charlson score. Patients with longer length of stay during primary admission and who discharged to short/long-term facility were more likely get readmitted and die in 90 days. Paradoxically, obese patients showed an inverse relationship with co-primary outcomes.

CONCLUSIONS

Older female patients were more likely to have a pulmonary embolism. High-risk groups such as heart failure, chronic pulmonary disease, anemia, and malignancy need to be given extra attention to prevent worse outcomes.

Targeted Treatment of Ischemic and Fibrotic Complications of Myocardial Infarction Using a Dual-Delivery Microgel Therapeutic

Myocardial infarction (MI), commonly known as a heart attack, affects millions of people worldwide and results in significant death and disabilities. A major cause of MI is fibrin-rich thrombus formation that occludes the coronary arteries, blocking blood flow to the heart and causing fibrin deposition. In treating MI, re-establishing blood flow is critical. However, ischemia reperfusion (I/R) injury itself can also occur and contributes to cardiac fibrosis. Fibrin-specific poly( N-isopropylacrylamide) nanogels (FSNs) comprised of a core-shell colloidal hydrogel architecture are utilized in this study to design a dual-delivery system that simultaneously addresses the need to (1) re-establish blood flow and (2) inhibit cardiac fibrosis following I/R injury. These therapeutic needs are met by controlling the release of a fibrinolytic protein, tissue plasminogen activator (tPA), and a small molecule cell contractility inhibitor (Y-27632). In vitro, tPA and Y-27632-loaded FSNs rapidly degrade fibrin and decrease cardiac cell stress fiber formation and connective tissue growth factor expression, which are both upregulated in cardiac fibrosis. In vivo, FSNs localize to fibrin in injured heart tissue and, when loaded with tPA and Y-27632, showed significant improvement in left ventricular ejection fraction 2 and 4 weeks post-I/R as well as significantly decreased infarct size, α-smooth muscle actin expression, and connective tissue growth factor expression 4 weeks post-I/R. Together, these data demonstrate the feasibility of this targeted therapeutic strategy to improve cardiac function following MI.

Could the use of bedside lung ultrasound reduce the number of chest x-rays in the intensive care unit?

Background

Lung ultrasound can be used as an alternative to chest radiography (CXR) for the diagnosis and follow-up of various lung diseases in the intensive care unit (ICU). Our aim was to evaluate the influence that introducing a routine daily use of lung ultrasound in critically ill patients may have on the number of CXRs and as a consequence, on medical costs and radiation exposure.

Methods

Data were collected by conducting a retrospective evaluation of the medical records of adult patients who needed thoracic imaging and were admitted to our academic polyvalent ICU. We compared the number of CXRs and relative costs before and after the introduction of lung ultrasound in our ICU.

Results

A total of 4134 medical records were collected from January 2010 to December 2014. We divided our population into two groups, before (Group A, 1869 patients) and after (Group B, 2265 patients) the introduction of a routine use of LUS in July 2012. Group A performed a higher number of CXRs compared to Group B (1810 vs 961, P = 0.012), at an average of 0.97 vs 0.42 exams per patient. The estimated reduction of costs between Groups A and B obtained after the introduction of LUS, was 57%. No statistically significant difference between the outcome parameters of the two groups was observed.

Conclusions

Lung ultrasound was effective in reducing the number of CXRs and relative medical costs and radiation exposure in ICU, without affecting patient outcome.

The prevalence and radiological findings of pulmonary embolism in HIV-positive patients referred for computed tomography pulmonary angiography in the Western Cape of South Africa

Aim:

To provide imaging data and report associations between human immunodeficiency virus (HIV), tuberculosis (TB) and pulmonary embolism (PE) in a South African population that underwent computed tomography pulmonary angiography (CTPA) for suspected PE.

Methods:

A validated Qanadli severity scoring system for PE was used for 164 CTPA scans, and parenchymal, pleural and cardiovascular complications were reported. Serological confirmation of HIV testing and microbiological confirmation of TB were recorded.

Results:

Prevalence of PE in the CTPA population was 26% (95% CI: 19.67–33.65%). HIV-positive prevalence in patients with PE was 67% (95% CI: 48.17–82.04%), however it was not statistically significantly different when compared with the patients without PE (p = 1). HIV-positive patients had more extensive partial thrombus in the right middle lobe (p = 0.045), but no other differences when compared with HIV-negative patients. TB prevalence in patients with PE was 57% (95% CI: 34.49–76.81%). This was statistically significantly different when compared with the patients without PE (p = 0.073 at the 10% level). Prevalence of TB co-morbidity in the HIV-positive group with proven PE was 71% (95% CI: 41.90– 91.61%), however there was no statistically significant difference in comparison with the HIV-negative patients with TB and PE (p= 0.305).

Conclusion:

The high number of patients presenting for CTPA who were HIV infected (and also infected with TB) highlights that PE evaluation should include severity/extent of the disease, as these patients may have more severe disease in specific lung lobes. The use of a validated scoring system, such as the Qanadli score, when reporting PE may have a profound effect on patient risk stratification, management and prognosis and would also provide a system for collecting larger volumes of data for analysis.

Diagnosis, prognosis and therapeutic management of acute pulmonary embolism

Pulmonary embolism (PE) is a leading cause of mortality worldwide. Recognizing PE and administering anticoagulants can significantly improve patient outcomes by reducing mortality rates and preventing recurrent events. For more than 50 years, standard therapy has involved parenteral anticoagulation followed by long-term therapy with the vitamin K antagonist warfarin. However, management of warfarin therapy is challenging due to its narrow therapeutic range and interactions with genetic and environmental factors. Direct oral anticoagulants (DOACs) have been developed to simplify anticoagulation and avoid the concerns associated with warfarin. DOACs are administered at a fixed dosage without routine monitoring and have few drug interactions. In recent years, DOACs have received FDA approval for the treatment of acute deep venous thrombosis (DVT) and PE based on the results of well-conducted clinical trials. This review discusses approaches to the diagnosis and treatment of PE and the use of DOACs as an alternative to warfarin treatment for the management of the disease. While many of the indications for DOACs and concepts discussed apply to both DVT and PE, our focus will be acute PE.

Venous thromboembolism: identifying patients at risk and establishing prophylaxis

Venous thromboembolism (VTE) is a major cause of morbidity and mortality and is associated with substantial healthcare costs. Identification of patients at risk of developing VTE enables appropriate thromboprophylaxis to be implemented. Although no predisposing risk factors can be identified in many patients in whom VTE develops, most have at least one underlying risk factor which can be categorized according to whether it confers low, moderate, or high risk. Clinical trials have demonstrated the effectiveness of thromboprophylaxis, both non-pharmacological and pharmacological, in a host of medical settings and there is sufficient evidence to support routine prophylaxis in many groups of patients. The implementation of decision making tools based on risk factor assessment improves the prescription of appropriate VTE prophylaxis. Nonetheless, thromboprophylaxis is often inadequate, with haphazard risk assessment and application of guidelines, leading to easily preventable instances of VTE. The most commonly used agents for pharmacological thromboprophylaxis of VTE are low dose unfractionated heparin; a low molecular weight heparin such as dalteparin, enoxaparin or tinzaparin; fondaparinux; warfarin; or aspirin. However, these have a number of drawbacks, principally the need for parenteral administration (with heparins) and frequent coagulation monitoring (with warfarin). The optimal anticoagulant would be orally administered, with a wide therapeutic window, rapid onset of action, predictable pharmacodynamics and pharmacokinetics, minimal interactions with food and other drugs, an ability to inhibit free and clot-bound coagulation factors, low, non-specific binding, and no requirement for routine coagulation monitoring or dose adjustment. A number of novel, single-target oral anticoagulants have been developed that appear to fulfill many of these requirements. This narrative review discusses the use of guidelines and risk assessment tools to identify patients at risk of VTE; it provides an overview of appropriate prophylaxis strategies in these patients with a summary of clinical trial results with novel oral anticoagulants.

Simplified CRB-65 for risk stratification and predicting prognosis in acute pulmonary embolism

Background: Pulmonary embolism (PE) and community acquired pneumonia (CAP) are potentially life-threatening diseases. In CAP CRB-65 is used for risk stratification and prognosis prediction. The aim of this study was to examine a simplified CRB-65 (sCRB-65) for predicting prognosis in PE.

Methods: We retrospectively analyzed the data of 182 PE patients. Patients were, according to the score of sCRB-65 (respectively 1 point for dyspnoea, systolic blood pressure < 90 mmHg or diastolic blood pressure60 mmHg, age65years), subdivided in risk-classes 1–4.

Risk classes were compared with Kruskal-Wallis test. Logistic multivariable regression and Pearson correlation matrix were calculated for coherence of sCRB-65 and in-hospital death, right ventricular load and PE severity stadium as well as sCRB-65 > 2points and in-hospital death an PE stadium. ROC analysis was performed to evaluate efficiency of sCRB-65 score to predict in-hospital death and PE severity stadium.

Results: PE severity stadium, systolic pulmonary artery pressure (sPAP) and frequency of in-hospital death increased with growing risk class.

Risk class 1 showed lower PE sever-ity stadium than 2 (P=0.0253), 3 (P=0.0132) and 4 (P=0.00162), lower percentage of patients with sPAP > 30mmHg than 2 (0 % vs. 48.9 %, P=0.0419), 3 (0 % vs. 70.8 %, P=0.00112) and 4 (0 % vs. 75.0 %, P=0.0113). Frequency of in-hospital deaths was higher in risk class 4 than in 1 (P=0.0024), 2 (P=0.00014) and 3 (P=0.000058). Multi-variable logistic regression showed an association between sCRB-65 scored>0 and PE severity stadium (OR 11.42, 95 %CI: 1.35–96.66, P=0.0254), RVD (OR 10.09, 1.16–87.78, P=0.0363) and sPAP (OR 1.08, 1.02–1.15, P=0.0092) as well as a trend towards significance (OR 12.39, 0.90–171.34, P=0.060) between in-hospital death and sCRB-65. sCRB-65 correlated with PE severity stadium (r=0.258, P<0.001) and sPAP (r=0.280, P=0.001). sCRB-65 >2 points was strongly associated with both inhospital death (OR 36.22, 95%CI: 1.59–827.71, P=0.0245) and high-risk PE stadium (OR 57.94, 95%CI: 7.17–468.33, P=0.000141). ROC analysis for CRB-65 predicting in-hospital death and high-risk PE stadium showed AUC values of respectively 0.764 and 0.892 with sCRB-65 cut-off value of 2.5 points, respectively.

Conclusions: sCRB-65 is closely correlated with PE severity stadium and load of the right heart as well as prognosis. PE patients with sCRB-65 score >2 points revealed a 36.2-fold risk to die during in-hospital course after acute PE event. Efficiency of sCRB-65 to predict in-hospital death was good.

Caval filters in intensive care: a retrospective study

AIM

To evaluate the effectiveness of a caval vein filter (CVF) peri-implant monitoring protocol in order to reduce pulmonary embolism (PE) mortality and CVF-related morbidity.

BACKGROUND

The reduction in mortality from PE associated with the use of CVF is affected by the risk of increase in morbidity. Therefore, CVF implant is a challenging prophylactic or therapeutic option. Nowadays, we have many different devices whose rational use, by applying a strict peri-implant monitoring protocol, could be safe and effective.

MATERIALS AND METHODS

We retrospectively studied 62 patients of a general Intensive Care Unit (ICU) scheduled for definitive, temporary, or optional bedside CVF implant. A peri-implant monitoring protocol including a phlebocavography, an echo-Doppler examination, and coagulation tests was adopted.

RESULTS

In our study, no thromboembolic recurrence was registered. We implanted 48 retrievable and only 20 definitive CVFs. Endothelial adhesion (18%), residual clot (5%), cranial or caudal migration (6%), microbial colonization of the filter in the absence of clinical signs of infection (1%), caval thrombosis (1%), and pneumothorax (1%) were reported. Deep-vein thrombosis (DVT) was reported (8%) as early complication. All patients with DVT had a temporary or optional filter implanted. However, in our cohort, definitive CVFs were reserved only to 32% of patients and they were not associated with DVT as complication.

CONCLUSION

CVF significantly reduces iatrogenic PE without affecting mortality. Generally, ICU patients have a transitory thromboembolic risk, and so the temporary CVF has been proved to be a first-line option to our cohort. A careful monitoring may contribute to a satisfactory outcome in order to promote CVF implant as a safe prophylaxis option.

Effect of delay in hospital presentation on clinical and imaging findings in acute pulmonary thromboembolism

BACKGROUND

There is limited information on the extent and clinical importance of the delay in hospital presentation of acute pulmonary thromboembolism (PTE).

OBJECTIVE

The aim of this study was to investigate the delay in hospital presentation of PTE and its association with clinical and imaging findings in PTE.

METHODS

This prospective study was conducted on patients admitted to our hospital with a diagnosis of acute PTE between September 2007 and September 2011. Relationships between delay in hospital presentation and clinical findings, risk factors, imaging findings, and in-hospital mortality were analyzed.

RESULTS

Of the 195 patients enrolled, 84 (43.1%) patients presented 3 days after the onset of symptoms. Patients with chest pain, history of immobility for more than 3 days, recent surgery, and estrogen use had significantly less delayed presentation. Right ventricular dysfunction was significantly more frequent in patients with delayed presentation (odds ratio [OR] = 2.38; 95% confidence interval [CI] 1.27-4.44; p = 0.006); however, no relationship was found between delay in presentation and pulmonary computed tomographic angiography or color Doppler sonography findings. Patients with delayed presentation were at higher risk of in-hospital mortality (OR = 4.32; 95% CI 1.12-16.49; p = 0.021).

CONCLUSIONS

Our study showed that a significant portion of patients with acute PTE had delayed presentation. Also, patients with delayed presentation had worse echocardiographic findings and higher in-hospital mortality.

Associations between presence of relevant information in referrals to radiology and prevalence rates in patients with suspected pulmonary embolism

RATIONALE AND OBJECTIVES

The purpose of this study was to assess if the presence of information including the pretest probability (Wells score), other known risk factors, and symptoms given on referrals for computed tomography (CT) pulmonary angiography correlated with prevalence rates for pulmonary embolism (PE). Also, to evaluate for differences between a university and a regional hospital setting regarding patient characteristics, amount of relevant information provided on referrals, and prevalence rates for pulmonary embolism.

MATERIALS AND METHODS

Retrospective review of all consecutive referrals (emergency room, inpatient, and outpatient) for CT performed on children and adults for suspected PE from two sites: a tertiary (university) hospital (site 1) and a secondary (regional) hospital (site 2) over a 5-year period.

RESULTS

The overall prevalence rate was 510/3641 or 14% of all referrals. Significantly higher number of males had a positive CT compared to women (18% versus 12%, P < .001). Although no statistically significant relationship between a greater amount of relevant information on the referral and the probability for positive finding existed, a slight trend was noted (P = .09). In two categories, "hypoxia" and "signs of deep vein thrombosis," the presence of this information conferred a higher probability for pulmonary embolism, P < .001. In the categories, "chest pain," "malaise," and "smoker/chronic obstructive pulmonary disease", the absence of information conferred a higher probability for pulmonary embolism.

CONCLUSIONS

The amount of relevant clinical information on the request did not correlate with prevalence rates, which may reflect a lack of documentation on the part of emergency physicians who may use a "gestalt" approach. Request forms likely did not capture all relevant patient risks and many factors may interact with each other, both positively and negatively. Pretest probability estimations were rarely performed, despite their inclusion in major society guidelines.