Venous Thromboembolism in the Intensive Care Unit
Pulmonary embolism is a common condition that, when unrecognized, is associated with a high mortality. The pathophysiologic complications of thromboembolism including hypotension and hypoxemia can necessitate intensive care unit management. In addition, p
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Scott J. Denstaedt and Thomas H. Sisson
Case Presentation Case Scenario A 72 year-old retired family physician with a history of hypertension and prostate cancer was admitted to the hospital with complaints of worsening dyspnea over 48 h. On presentation, he was tachycardic with a heart rate 112, tachypneic with a respiratory rate of 22, normotensive with a blood pressure of 110/70 and his pulse oximetry revealed an O2 saturation of 88 % on room air. He had 2+ left lower extremity edema (with trace edema on the right). A chest x-ray showed no acute cardiopulmonary disease, and his EKG revealed sinus tachycardia with non-specific T wave changes. Laboratory studies were within normal limits with the exception of a troponin I which was elevated to 1.5 ng/ml (reference 65–75, renal failure, INR > 1.7 and female gender which may contribute directly to bleeding risk [1, 34, 35] (Table 25.6). However, it is unclear how these risk factors should modify clinical practice. Therefore, until further data is available, it remains at the clinician’s discretion to determine whether the potential benefits of
S.J. Denstaedt and T.H. Sisson
reperfusion treatment outweigh the risks of hemorrhagic complications in the individual patient.
IVC Filter Placement Beyond using IVC filters for patients who cannot be anti-coagulated due to a heightened bleeding risk, it has been hypothesized that the employment of these devices in conjunction with heparin might improve outcomes in high risk PE patients. This hypothesis was best addressed in a recent trial in which patients with acute pulmonary embolism, lower-extremity venous thrombosis, and at least 1 additional risk factor were randomized to treatment with a retrievable inferior vena cava filter plus anticoagulation (n = 200) or anticoagulation alone (n = 199) [36]. Retrievable filters were used in light of previous evidence demonstrating an increased risk of DVT in patients with permanent devices, and the study protocol called for removal at 3 months post-deployment (which occurred successfully in 153 of 164 attempts). The primary endpoint of this study was symptomatic recurrent PE at 3 months, and this event occurred rarely. Furthermore, there was no difference in this outcome between the two groups. Specifically, six patients who had received a filter experienced a recurrent PE (3.0 %, all fatal) while three patients (1.5 %, two fatal) in the control group received this diagnosis (p = .50). The results of this study are consistent with an investigation in cancer patients in which filter placement had no effect on the incidence of PE, but again the event rates were low (3 %) [37]. Whether temporary filter placement in hemodynamically unstable PE patients, particularly those individuals already undergoing catheter-directed thrombolysis in Interventional Radiology, is beneficial has not been adequately studied, and this approach is at the preference of the treating physician.
irect Factor Xa and Thrombin D Inhibitors Recent studies indicate that direct factor Xa and thrombin i
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