Tissue perfusion alterations correlate with mortality in patients admitted to the intensive care unit for acute pulmonary embolism

Venous duplex scan (VDS) has been used for interim bedside diagnosis of pulmonary embolism (PE) in severely injured patients deemed to be at risk if transported out of the intensive care unit. In combination with the level of clinical suspicion for PE, VDS helps select patients for temporary treatment until definitive diagnosis is made. We evaluate the sensitivity and specificity of VDS in critically injured patients with a high level of clinical suspicion for PE. We performed a prospective observational cohort study at the surgical intensive care unit of an academic level 1 trauma center. Patients were 59 critically injured patients suspected to have PE over a 30-month period. The level of clinical suspicion for PE was classified as low or high according to preset criteria. Interventions were VDS and a PE outcome test (conventional or computed tomographic pulmonary angiography). The sensitivity and specificity of VDS to detect PE in all patients and in patients with high level of clinical suspicion was calculated against the results of the outcome test. PE was diagnosed in 21 patients (35.5%). The sensitivity and specificity of VDS was 33 per cent and 89 per cent, respectively. Among the 28 patients who had a high level of clinical suspicion for PE, the sensitivity of VDS was 23 per cent and the specificity 93 per cent. In this latter population, 1 of the 4 (25%) positive VDS was of a patient without PE and 10 of the 24 (42%) negative VDS were of patients who had PE. VDS does not accurately predict PE in severely injured patients, even in the presence of a high level of clinical suspicion.

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Delayed pulmonary embolism after COVID-19 pneumonia: a case report

European Heart Journal - Case Reports ◽

10.1093/ehjcr/ytaa449 ◽

2020 ◽

Author(s):

Mohamad Kanso ◽

Thomas Cardi ◽

Halim Marzak ◽

Alexandre Schatz ◽

Loïc Faucher ◽

...

Keyword(s):

Risk Factors ◽

Intensive Care Unit ◽

Pulmonary Embolism ◽

Acute Pulmonary Embolism ◽

Index Hospitalization ◽

Rt Pcr ◽

Moderate Severity ◽

Respiratory Status ◽

Case Summary ◽

Pcr Test

Abstract Background Since the onset of the COVID-19 pandemic, several cardiovascular manifestations have been described. Among them, venous thromboembolism (VTE) seems to be one of the most frequent, particularly in intensive care unit patients. We report two cases of COVID-19 patients developing acute pulmonary embolism (PE) after discharge from a first hospitalization for pneumonia of moderate severity. Case summary Two patients with positive RT-PCR test were initially hospitalized for non-severe COVID-19. Both received standard thromboprophylaxis during the index hospitalization and had no strong predisposing risk factors for VTE. Few days after discharge, they were both readmitted for worsening dyspnoea due to PE. One patient was positive for lupus anticoagulant. Discussion Worsening respiratory status in COVID-19 patients must encourage physicians to search for PE since SARS-CoV-2 infection may act as a precipitant risk factor for VTE. Patients may thus require more aggressive and longer thromboprophylaxis after COVID-19 related hospitalization.

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Abstract 13317: Acute Pulmonary Embolism in Covid-19 Patients: Presenting Characteristics, Outcomes and Risk Stratification Strategies

Circulation ◽

10.1161/circ.142.suppl_3.13317 ◽

2020 ◽

Vol 142 (Suppl_3) ◽

Author(s):

Hai Xu ◽

Angel Martin ◽

Avneet SINGH ◽

Mangala Narasimhan ◽

Joe Lau ◽

...

Keyword(s):

Pulmonary Embolism ◽

Intensive Care ◽

Mortality Rate ◽

Length Of Stay ◽

Risk Stratification ◽

Clinical Outcomes ◽

Acute Pulmonary Embolism ◽

Severe Bleeding ◽

Study Cohort ◽

D Dimer

Introduction: Pulmonary Embolism in coronavirus disease 2019 (COVID-19) patients have been increasingly reported in observational studies. However, limited knowledge describing their diagnostic features and clinical outcomes exist to date. Our study aims to systemically analyze their clinical characteristics and to investigate strategies for risk stratification. Methods: We retrospectively studied 101 patients with concurrent diagnoses of acute pulmonary embolism and COVID-19 infection, admitted at two tertiary hospitals within the Northwell Health System in New York City area. Clinical features including laboratory and imaging findings, therapeutic interventions, intensive care unit (ICU) admission, mortality and length of stay were recorded. D-dimer values were respectively documented at COVID-19 and PE diagnoses for comparison. Pulmonary Severity Index (PESI) scores were used for risk stratification of clinical outcomes. Results: The most common comorbidities were hypertension (50%), obesity (27%) and hyperlipidemia (32%) among our study cohort. Baseline D-dimer abnormalities (4647.0 ± 8281.8) were noted on admission with a 3-fold increase at the time of PE diagnosis (13288.4 ± 14917.9; p<0.05). 5 (5%) patients required systemic thrombolysis and 12 (12%) patients experienced moderate to severe bleeding. 31 (31%) patients developed acute kidney injury (AKI) and 1 (1%) patient required renal replacement therapy. Throughout hospitalization, 23 (23%) patients were admitted to intensive care units, of which 20 (20%) patients received invasive mechanical ventilation. The overall mortality rate was 20%. Majority of patients (65%) had Intermediate to high risk PESI scores (>85), which portended a worse prognosis with higher mortality rate and length of stay. Conclusions: This study provides characteristics and early outcomes for hospitalized patients with COVID-19 and acute pulmonary embolism. D-dimer levels and PESI scores may be utilized to risk stratify and guide management in this patient population. Our results should serve to alert the medical community to heighted vigilance of this VTE complication associated with COVID-19 infection, despite the preliminary and retrospective nature inherent to this study.

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Venous Thrombosis and SARS-CoV-2

Hämostaseologie ◽

10.1055/a-1661-0283 ◽

2021 ◽

Author(s):

Monika Zdanyte ◽

Dominik Rath ◽

Meinrad Gawaz ◽

Tobias Geisler

Keyword(s):

Intensive Care Unit ◽

Pulmonary Embolism ◽

Intensive Care ◽

Venous Thromboembolism ◽

Vascular Endothelium ◽

Arterial Thrombosis ◽

Review Article ◽

Prevention And Treatment ◽

All Cause Mortality ◽

Thrombotic Complications

AbstractSARS-CoV-2 (severe acute respiratory syndrome coronavirus 2) infection is associated with high risk of venous and arterial thrombosis. Thrombotic complications, especially pulmonary embolism, lead to increased all-cause mortality in both intensive care unit and noncritically ill patients. Damage and activation of vascular endothelium, platelet activation, followed by thrombotic and fibrinolytic imbalance as well as hypercoagulability are the key pathomechanisms in immunothrombosis leading to a significant increase in thromboembolism in coronavirus disease 2019 (COVID-19) compared with other acute illnesses. In this review article, we discuss the incidence and prognosis, diagnosis, prevention, and treatment of venous thromboembolism in patients with COVID-19 disease, based on clinical experience and research available to date.

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Cardiopulmonary support in the intensive care unit

American Journal of Critical Care ◽

10.4037/ajcc1992.1.1.98 ◽

1992 ◽

Vol 1 (1) ◽

pp. 98-106

Author(s):

M Cone ◽

M Hoffman ◽

D Jessen ◽

P Posa ◽

C Dailey ◽

...

Keyword(s):

Intensive Care Unit ◽

Intensive Care ◽

Tissue Perfusion ◽

Definitive Treatment ◽

Critically Ill Patient ◽

Careful Monitoring ◽

Cardiopulmonary Support ◽

Critical Care Team ◽

Adequate Tissue ◽

Cardiopulmonary Support System

The cardiopulmonary support system is an extracorporeal device that allows for rapid cardiopulmonary support of the critically ill patient in the intensive care unit. It provides immediate and complete support of cardiac and pulmonary functions to maintain perfusion to vital organs in patients who are severely physiologically compromised (eg, in cardiogenic shock, adult respiratory distress syndrome or pulmonary edema). Successful cardiopulmonary support requires systemic anticoagulation, percutaneous venous and arterial cannulation and careful monitoring by the critical care team to maintain adequate tissue perfusion and oxygenation. Although patient mortality can occur secondary to bleeding, embolism or sepsis, this technique provides life-sustaining circulatory and respiratory support until definitive treatment can be initiated.

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Outcomes of Triggering the Emergency Response Team at a High-Volume Arthroplasty Center

Scandinavian Journal of Surgery ◽

10.1177/1457496919857263 ◽

2019 ◽

Vol 109 (4) ◽

pp. 336-342 ◽

Cited By ~ 1

Author(s):

S. A. Saku ◽

R. Linko ◽

R. Madanat

Keyword(s):

Intensive Care Unit ◽

Pulmonary Embolism ◽

Intensive Care ◽

Intensive Care Unit Admission ◽

Emergency Response ◽

Medical Records ◽

High Volume ◽

Low Oxygen ◽

Response Team ◽

The Mean

Background and Aims: Emergency Response Teams have been employed by hospitals to evaluate and manage patients whose condition is rapidly deteriorating. In this study, we aimed to assess the outcomes of triggering the Emergency Response Teams at a high-volume arthroplasty center, determine which factors trigger the Emergency Response Teams, and investigate the main reasons for an unplanned intensive care unit admission following Emergency Response Team intervention. Material and Methods: We gathered data by evaluating all Emergency Response Team forms filled out during a 4-year period (2014–2017), and by assessing the medical records. The collected data included age, gender, time of and reason for the Emergency Response Teams call, and interventions performed during the Emergency Response Teams intervention. The results are reported as percentages, mean ± standard deviation, or median (interquartile range), where appropriate. All patients were monitored for 30 days to identify possible intensive care unit admissions, surgeries, and death. Results: The mean patient age was 72 (46–92) years and 40 patients (62%) were female. The Emergency Response Teams was triggered a total of 65 times (61 patients). The most common Emergency Response Team call criteria were low oxygen saturation, loss or reduction of consciousness, and hypotension. Following the Emergency Response Team call, 36 patients (55%) could be treated in the ward, and 29 patients (45%) were transferred to the intensive care unit. The emergency that triggered the Emergency Response Teams was most commonly caused by drug-related side effects (12%), pneumonia (8%), pulmonary embolism (8%), and sepsis (6%). Seven patients (11%) died during the first 30 days after the Emergency Response Teams call. Conclusion: Although all 65 patients met the Emergency Response Teams call criteria, potentially having severe emergencies, half of the patients could be treated in the arthroplasty ward. Emergency Response Team intervention appears useful in addressing concerns that can potentially lead to unplanned intensive care unit admission, and the Emergency Response Teams trigger threshold seems appropriate as only 3% of the Emergency Response Teams calls required no intervention.

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Use of hospital resources in the care of patients with intermediate risk pulmonary embolism

European Heart Journal Acute Cardiovascular Care ◽

10.1177/2048872620921601 ◽

2020 ◽

pp. 204887262092160

Author(s):

Alexander E Sullivan ◽

Tara Holder ◽

Tracy Truong ◽

Cynthia L Green ◽

Olamiji Sofela ◽

...

Keyword(s):

Intensive Care Unit ◽

Pulmonary Embolism ◽

Intensive Care ◽

High Risk ◽

Length Of Stay ◽

Intensive Care Unit Admission ◽

Hospital Length ◽

Hospital Length Of Stay ◽

Intermediate Risk ◽

Risk Patients

Background Risk stratification and management of hemodynamically stable pulmonary embolism remains challenging. Professional societies have published stratification schemes, but little is known about the management of patients with intermediate risk pulmonary embolism. We describe the care of these patients at an academic health system. Methods Patient encounters from 1 January 2016 to 30 June 2017 were retrospectively identified utilizing a multihospital, electronic health record-based data warehouse. Using the 2019 European Society of Cardiology criteria, differences in hospital resource utilization, defined as intensive care unit admission, use of invasive therapies, and length of stay, were examined in patients with intermediate risk characteristics. Results A cohort of 322 intermediate risk patients, including 165 intermediate–low and 157 intermediate–high risk patients, was identified. Intermediate–high risk patients more often underwent catheter-directed therapy (14.0% vs. 1.8%; P<0.001) compared to intermediate–low risk patients and had a 50% higher rate of intensive care unit admission (relative risk 1.50; 95% confidence interval 1.06, 2.12; P=0.023). There was no difference in median intensive care unit length of stay (2.7 vs. 2.0 days; P=0.761) or hospital length of stay (5.0 vs. 5.0 days; P=0.775) between intermediate–high risk and intermediate–low risk patients. Patients that underwent invasive therapies had a 3.8-day shorter hospital length of stay (beta –3.75; 95% confidence interval –6.17, –1.32; P=0.002). Conclusion This study presents insights into the hospital resource utilization of patients with intermediate risk pulmonary embolism. The 2019 European Society of Cardiology risk stratification criteria are a clinically relevant scheme that identifies patients more often treated with intensive care unit admission and advanced therapies.

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