Perioperative Pulmonary Embolism Prevention and Treatment

Review Article

Austin Spine. 2017; 1(1): 1001.

Asthma and Cesarean Section

Huang J¹*, Lu Y² and Chen J¹

¹Department of Medicine, University of Central Florida, USA

²Department of Medicine, Hennepin County Medical Center, USA

*Corresponding author: Huang J, Department of Medicine, University of Central Florida, Orlando, FL, USA

Received: January 05, 2017; Accepted: February 02, 2017; Published: February 06, 2017

Abstract

All perioperative patients are at an increased risk of pulmonary embolism and venous thromboembolism. Perioperative massive Pulmonary Embolism (PE) is a significant cause of morbidity and mortality. Clinical outcomes have been shown to be improved by a high index of suspicion, prompt recognition, and aggressive intervention. It is important that healthcare providers recognize perioperative PE and know prevention and treatment options. Many medical societies have published guideline recommendations for management of PE. In this review, we will focus on perioperative acute PE treatment and prevention to implement guideline recommendations for optimizing management of acute PE.

Keywords: Pulmonary Embolism; Diagnosis; Thrombolytic agents; Prevention

Introduction

Massive perioperative Pulmonary Embolism (PE) is an uncommon event but significant cause of morbidity and mortality. It is estimated that PE is responsible for between 150,000 and 200,000 deaths per year in the United States [1]. 30% of the deaths from PE take place during the perioperative period [1]. PE is the third most common cardiovascular disease after myocardial infarction and cerebrovascular accident (stroke). Several studies have reported mortality rates ranging from 15% to 30%, while mortality rates in a massive PE can reach 30% to 50% [2-4]. A recent review of more than 3000 massive intraoperative thromboembolic events revealed an overall mortality of 41% [5].

Surgery increases the risks for perioperative PE. Healthcare providers, including anesthesiologists, are responsible for the diagnosis and treatment of perioperative PE. During surgery, PE often first presents with hemodynamic instability and if progressing quickly, can lead to death. It is important that healthcare providers recognize perioperative PE and know prevention and treatment options. Prompt diagnosis and treatment can save patient lives. In this review, we will focus on perioperative acute PE treatment and prevention.

Diagnosis of PE

Diagnosis of a PE in the perioperative period can be a challenge, but early detection can reduce morbidity. The American Heart Association (AHA) classified and defined PE into three classes: massive PE, submassive PE, and low-risk PE [6].

Definition for massive PE: Acute PE with sustained hypotension (systolic blood pressure <90 mm Hg for at least 15 minutes or requiring isotropic support, not due to a cause other than PE, such as arrhythmia, hypovolemia, sepsis, or Left Ventricular (LV) dysfunction), pulselessness, or persistent profound bradycardia (heart rate<40 bpm with signs or symptoms of shock) [6].

Definition for submassive PE: Acute PE without systemic hypotension (systolic blood pressure = 90 mm Hg) but with either RV dysfunction or myocardial necrosis [6].

RV dysfunction means the presence of at least 1 of the following: (1) RV dilation (apical 4-chamber RV diameter divided by LV diameter >0.9) or RV systolic dysfunction on echocardiography. (2) RV dilation (4-chamber RV diameter divided by LV diameter >0.9) on CT. (3) Elevation of BNP (>90 pg/mL). (4) Elevation of N-terminal pro-BNP (>500 pg/mL); or (5) Electrocardiographic changes (new complete or incomplete right bundle-branch block

ST elevation or depression, or anteroseptal T-wave inversion).

Myocardial necrosis is defined as either of the following: (1) Elevation of troponin I (>0.4 ng/mL) or (2) Elevation of troponin T (>0.1 ng/mL).

Definition for low-risk PE: Acute PE and the absence of the clinical markers of adverse prognosis that define massive or submassive PE [6].

The Treatment of Acute Pulmonary Embolism

Systemic thrombolysis

Thrombolytic agents are indicated in patients who are normotensive but with evidence of RV failure or in cases of hemodynamic instability [7]. Several societies guidelines advocate the use of thrombolytic agent in patients with hemodynamic compromise and massive PE is acceptable [6,8].

A meta-analysis of clinical trials including patients with massive PE showed IV fibrinolytic agents reduced the composite of recurrent PE and death, but not in death alone [9]. The results of patients with submassive PE were better characterized in randomized trials. These studies showed the use of IV fibrinolytic therapy in patients with massive or submassive PE can improve hemodynamic stability and, possibly reduce the risk of recurrent PE and PE-attributed death [10].

The most commonly used thrombolytic agents approved by the US Food and Drug Administration (FDA) for acute PE included: Recombinant tissue type Plasminogen Activator (tPA, alteplase), Streptokinase (SK) and recombinant human Urokinase (UK). Other thrombolytic agents not FDA approved include tenecteplase and reteplase.

All fibrinolytic drugs are enzymes that convert the patient’s native circulating plasminogen into plasmin. The contraindications include active internal bleeding; prior intracranial hemorrhage, intracranial cerebrovascular disease, suspected aortic dissection, intracranial malignant neoplasm, ischemic stroke within 3 months, recent intracranial or spinal cord surgery, recent closed-head or facial trauma with fracture or intracerebral injury [6], and severe uncontrolled hypertension [11].

Streptokinase should also not be used after 5 days to 12 months of initial use for possible anaphylactic reaction from anti-streptokinase antibodies or in patients with recent streptococcal infections due to possible drug resistance or reduced effects (Table 1) [12-15] .