Advanced Cardiopulmonary Support for Pulmonary Embolism.
Management of high-risk pulmonary embolism (PE) requires an understanding of the pathophysiology of PE, options for rapid clot reduction, critical care interventions, and advanced cardiopulmonary support. PE can lead to rapid respiratory and hemodynamic collapse via a complex sequence of events leading to acute right ventricular failure. Importantly, reduction in pulmonary vascular resistance must be accomplished either by systemic thrombolytics, catheter directed thrombolytics, endovascular clot extraction, or surgical embolectomy. There are important advances in these techniques all of which have a niche role in the cardiopulmonary stabilization of critically ill patient with PE. Critical care support surrounding the above interventions is necessary. Maintenance of systemic perfusion and cardiac output may require careful titration of vasopressors, inotropes, and preload. Extreme caution should be taken with approach to intubation and positive pressure ventilation. A hemodynamically neutral induction with preparations for circulatory collapse should be the goal. Once intubated, the effect of positive pressure on pulmonary vascular resistance and right ventricular hemodynamics is necessary. Veno-arterial extra corporeal membrane oxygenation plays an increasingly important role in the stabilization of the hemodynamically collapsed patient who either has a contraindication to systemic lytics, failed systemic lytics, or requires a bridge to surgical or catheter embolectomy. Veno-arterial extra corporeal membrane oxygenation has also been used alone to stabilize the circulation until hemodynamics normalize on anticoagulation and has also been used in tenuous patient as a safety net for endovascular procedures.
['Friedman|Oren|O|', 'Horowitz|James M|JM|', 'Ramzy|Danny|D|']
D002319:Cardiovascular System D003131:Combined Modality Therapy D016638:Critical Illness D017128:Embolectomy D057510:Endovascular Procedures D015199:Extracorporeal Membrane Oxygenation D006353:Heart-Assist Devices D006439:Hemodynamics D006801:Humans D011655:Pulmonary Embolism D020127:Recovery of Function D012119:Respiration D012121:Respiration, Artificial D012137:Respiratory System D012307:Risk Factors D015912:Thrombolytic Therapy D016896:Treatment Outcome
pulmonary embolism ECMO RV failure catheter directed lysis high-risk PE