Pulmonary embolectomy in high-risk acute pulmonary embolism: The effectiveness of a comprehensive therapeutic algorithm including extracorporeal life support

Abstract Background The use of extracorporeal membrane oxygenation (ECMO) in critically ill adults is increasing. Patients on ECMO are at high risk for infections, with 20.5% of adults acquiring infections while on ECMO. An Extracorporeal Life Support Organization (ELSO) Infectious Disease Task Force statement concluded that no antibiotic prophylaxis is needed for patients on ECMO though it also noted that this was based on limited data. We implemented an antimicrobial prophylaxis protocol for patients on ECMO at our institution and analyzed antimicrobial use and outcomes in these patients with a pre- and post-analysis. Methods We conducted a retrospective review of 294 patients on ECMO between July 1, 2011 and July 1, 2017. An ECMO antimicrobial prophylaxis guideline was initially implemented on July 1, 2014; there was poor adherence to the guideline and antimicrobial use actually increased. A more restrictive protocol was implemented in November 2018 with input from stakeholders including cardiac surgeons, critical care and infectious disease (ID) providers. We had a cohort of 161 patients before (July 2014–November 2018) and 37 patients after (November 2018–April 2018) the implementation of the updated protocol. We evaluated primary outcomes of gross days of antimicrobial use, percent of antibiotic-free days and days of individual antimicrobial use, adjusted for APACHE scores and ECMO duration. Results When adjusted for days on ECMO, mean antibiotic days decreased after implementation of the protocol; for vancomycin (0.27 vs. 0.02, P < 0.0003), cefepime (0.15 vs. 0.02, P < 0.02), meropenem (0.09 vs. 0, P < 0.02), zosyn (0.16 vs. 0, P < 0.002), caspofungin (0.346, 0.138 P < 0.003). This was accompanied by a nonsignificant increase in mean fluconazole use (0.29 vs. 0.37, P < 0.3). There was no impact on patient mortality or nosocomial infection rate. Additional results can be found in table. Conclusion The use of an antimicrobial prophylaxis protocol in ECMO patients led to improvement in antimicrobial usage without increasing nosocomial infections in a population at a high risk of infection. Disclosures All authors: No reported disclosures.

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Risk stratification in normotensive acute pulmonary embolism patients: focus on the intermediate–high risk subgroup

European Heart Journal Acute Cardiovascular Care ◽

10.1177/2048872619846506 ◽

2019 ◽

Vol 9 (4) ◽

pp. 279-285 ◽

Cited By ~ 2

Author(s):

Ana Rita Santos ◽

Pedro Freitas ◽

Jorge Ferreira ◽

Afonso Oliveira ◽

Mariana Gonçalves ◽

...

Keyword(s):

Pulmonary Embolism ◽

High Risk ◽

Risk Stratification ◽

Right Ventricular ◽

Acute Pulmonary Embolism ◽

Ventricular Dysfunction ◽

Right Ventricular Dysfunction ◽

Cardiac Biomarkers ◽

Cardiac Biomarker ◽

Imaging Signs

Background: Patients with acute pulmonary embolism are at intermediate–high risk in the presence of imaging signs of right ventricular dysfunction plus one or more elevated cardiac biomarker. We hypothesised that intermediate–high risk patients with two elevated cardiac biomarkers and imaging signs of right ventricular dysfunction have a worse prognosis than those with one cardiac biomarker and imaging signs of right ventricular dysfunction. Methods: We analysed the cumulative presence of cardiac biomarkers and imaging signs of right ventricular dysfunction in 525 patients with intermediate risk pulmonary embolism (intermediate-high risk = 237) presenting at the emergency department in two centres. Studied endpoints were composites of all-cause mortality and/or rescue thrombolysis at 30 days (primary endpoint; n=58) and pulmonary embolism-related mortality and/or rescue thrombolysis at 30 days (secondary endpoint; n=40). Results: Patients who experienced the primary endpoint showed a higher proportion of elevated troponin (47% vs. 76%, P<0.001), elevated N-terminal pro-brain natriuretic peptide (67% vs. 93%, P<0.001) and imaging signs of right ventricular dysfunction (47% vs. 80%, P<0.001). Multivariate analysis revealed N-terminal pro-brain natriuretic peptide (hazard ratio (HR) 3.6, 95% confidence interval (CI) 1.3–10.3; P=0.015) and imaging signs of right ventricular dysfunction (HR 2.8, 95% CI 1.5–5.2; P=0.001) as independent predictors of events. In the intermediate–high risk group, patients with two cardiac biomarkers performed worse than those with one cardiac biomarker (HR 3.3, 95% CI 1.8–6.2; P=0.003). Conclusions: Risk stratification in normotensive pulmonary embolism should consider the cumulative presence of cardiac biomarkers and imaging signs of right ventricular dysfunction, especially in the intermediate–high risk subgroup.

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Outcomes of extracorporeal life support for the treatment of acute massive pulmonary embolism: A systematic review

Resuscitation ◽

10.1016/j.resuscitation.2019.11.018 ◽

2020 ◽

Vol 146 ◽

pp. 132-137 ◽

Cited By ~ 3

Author(s):

Thomas J. O’Malley ◽

Jae Hwan Choi ◽

Elizabeth J. Maynes ◽

Chelsey T. Wood ◽

Nicholas D. D’Antonio ◽

...

Keyword(s):

Systematic Review ◽

Pulmonary Embolism ◽

Life Support ◽

Extracorporeal Life Support ◽

Massive Pulmonary Embolism

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Acute pulmonary embolism: mortality prediction by the 2014 European Society of Cardiology risk stratification model

European Respiratory Journal ◽

10.1183/13993003.00024-2016 ◽

2016 ◽

Vol 48 (3) ◽

pp. 780-786 ◽

Cited By ~ 90

Author(s):

Cecilia Becattini ◽

Giancarlo Agnelli ◽

Mareike Lankeit ◽

Luca Masotti ◽

Piotr Pruszczyk ◽

...

Keyword(s):

Pulmonary Embolism ◽

High Risk ◽

Risk Stratification ◽

Negative Predictive Value ◽

European Society ◽

Predictive Value ◽

Acute Pulmonary Embolism ◽

Risk Stratification Model ◽

Risk Patients ◽

European Society Of Cardiology

The European Society of Cardiology (ESC) has proposed an updated risk stratification model for death in patients with acute pulmonary embolism based on clinical scores (Pulmonary Embolism Severity Index (PESI) or simplified PESI (sPESI)), right ventricle dysfunction (RVD) and elevated serum troponin (2014 ESC model).We assessed the ability of the 2014 ESC model to predict 30-day death after acute pulmonary embolism. Consecutive patients with symptomatic, confirmed pulmonary embolism included in prospective cohorts were merged in a collaborative database. Patients’ risk was classified as high (shock or hypotension), intermediate-high (RVD and elevated troponin), intermediate-low (RVD or increased troponin or none) and low (sPESI 0). Study outcomes were death and pulmonary embolism-related death at 30 days.Among 906 patients (mean±sd age 68±16, 489 females), death and pulmonary embolism-related death occurred in 7.2% and 4.1%, respectively. Death rate was 22% in “high-risk” (95% CI 14.0–29.8), 7.7% in “intermediate-high-risk” (95% CI 4.5–10.9) and 6.0% in “intermediate-low-risk” patients (95% CI 3.4–8.6). One of the 196 “low-risk” patients died (0.5%, 95% CI 0–1.0; negative predictive value 99.5%).By using the 2014 ESC model, RVD or troponin tests would be avoided in about 20% of patients (sPESI 0), preserving a high negative predictive value. Risk stratification in patients at intermediate risk requires further improvement.

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