Acute Management of Pulmonary Embolism Dr Alex West Respiratory Consultant Guy s and St Thomas Hospital London
Declarations - none
Order of Play Up date in Diagnostic Imaging - CTPA and V:Q SPECT Sub-massive PE - How to assess - Pragmatic approach to decision thrombolysis - Catheter directed thrombolysis
Up date in Diagnostic Imaging Get the diagnosis right at the start
Standard V/Q scan Planar images Camera is stationary over the patient Acquires an image from this one angle, like an x-ray
Planar image
SPECT Single Photon Emission Computed Tomography Camera rotates around the patient, gets images from a variety of angles Can then reconstruct 3-dimensional view
SPECT how it works Camera head rotates around patient
Normal SPECT image PERF VENT PERF VENT A X I A L C O R O N PERF VENT S A G I T
Abnormal PERF VENT PERF VENT PERF VENT
False positives?
False positives
Consolidation
Dose of Radiation Worst case scenario:- Perfusion (technetium): 2.2mSv Ventilation (krypton): 0.29mSv Ventilation (technetium): 1mSv 1mSv: 1 in 20,000 chance of fatal cancer 1 year in London: 2 msv 1 year in Cornwall: 8 msv
CTPA Plus New Scanners dual tubes & voltages Can detect specific eg calcium, iodine Measure volume of iodine per pixel shown in colour Dose of radiation same or even less. Need less contrast (eg renal failure)
Dual energy CTPA- CTPA image only- left pulm art filling defect Fused iodine and CT Iodine map= perfusion map - marked decreased perfusion in left lung Virtual non-contrast CT- allows us to remove iodine and we can therefore see if an intravascular mass virtually enhances
Definitions of PE
Massive PE SBP < 90 mmhg or drop of >40 mmhg >15 mins with no other cause Up to 5-10% of patients Mortality high (15-58%)
Massive PE - Treatment Resuscitation Full Dose systemic thrombolysis tpa 10mg bolus, 90mg / 2 hours Risk of major bleeding (6-20%) Intracranial Haemorrhage (2-6%).But outweighs risk of death from PE
Sub-massive PE Not hypotensive but Evidence of right heart dysfunction Evidence of myocardial injury elevated Troponin, BNP Confirmed large clot burden CTPA (V:Q) Mortality or Adverse Events 3-25%?
So why not thrombolyse too? (Excellent Pro/Con Debate at this meeting 2 years ago Overwhelming NO!) And Thorax Pro/Con Debate
So why not thrombolyse too? (Excellent Pro/Con Debate at this meeting 2 years ago Overwhelming NO!) And Thorax Pro/Con Debate
Adverse Events from Sub-Massive PE
American Guidelines Chest 2016 Sub-massive PE
American Guidelines Chest 2016 *23. In selected patients with acute PE who deteriorate after starting anticoagulant therapy but have yet to develop hypotension and who have a low bleeding risk, we suggest systemically administered thrombolytic therapy over no such therapy (Grade 2C).
American Guidelines Chest 2016 *23. In selected patients with acute PE who deteriorate after starting anticoagulant therapy but have yet to develop hypotension and who have a low bleeding risk, we suggest systemically administered thrombolytic therapy over no such therapy (Grade 2C)..Dose not suggested
MOPETT Trial Concept of Safe Dose Thrombolysis? Cardiac output Brain 15%, Heart 5%, Pulmonary 100% tpa - 10mg bolus tpa - 40mg/2 hours (0.5mg/kg if <50kg)
MOPETT Trail
MOPETT Trail
PERT
A Pragmatic British Alternative And applicable to DGH as teaching hospitals alike
PE Lysis Team- PELT Chest Physicians Critical Care Haematologists Interventional Radiology (Obstetric Physician)
PE Lysis Team- PELT Chest Physicians Critical Care Haematologists Interventional Radiology (pt bleeding risk) (Obstetric Physician)
Sub-massive PE Not shocked but Evidence of right heart dysfunction Evidence of myocardial injury elevated Troponin, BNP Confirmed large clot burden CTPA (V:Q) Mortality or Adverse Events 3-15%?
Sub-massive PE Not shocked but Evidence of right heart dysfunction* Evidence of myocardial injury elevated Troponin*, BNP* Confirmed large clot burden* - CTPA (V:Q) Mortality or Adverse Events 3-15%... Predictors* both +ve and -ve
PE Lysis Team- PELT Initial Clinical Assessment ECHO Bilateral leg Dopplers Bleeding risk (NB age, Pulmonary infarction)
PE Lysis Team- PELT Initial Clinical Assessment ECHO Bilateral leg Dopplers Bleeding risk (NB age, Pulmonary infarction) Serial Assessment review progress Patient involvement in decisions/consent..then you make a TEAM judgement
Local Protocol for Sub-Massive PE Team decision Done in level 2 or 3 Systemic half dose first line Catheter direct Thrombolysis for - bleeding risk (eg post surgery) - Second line (post systemic, including massive PE) - Older Clot? (Local outcome very good thus far)
Catheter Directed Thrombolysis Interventional Radiology Time is situ 12-24 hours Infuse tpa 0.5-1mg per hour Lower total dose Can be bilateral (and each side adjusted ) Still risk of bleeding and arrhythmia
EKOS Endovascular System Features 50
Acoustic Pulse Thrombolysis treatment Mechanism of action Fibrin Separation Ultrasound separates fibrin without fragmentation of emboli Active Drug Delivery Drug is actively driven into clot by Acoustic Streaming EKOS Acoustic Pulse Thrombolysis treatment is a minimally invasive system for accelerating thrombus dissolution. 51
Question? 34yo lady, 33/40 pregnant. V:Q Significant bilateral PEs. BP 115/78. Tachy 110, 60% O2, RR24, sats 91%. Has had 2/7 full dose LMWH, no better, moved to ICU for closer monitoring A: Continue Fragmin B: iv heparin C: Cather Directed Thrombolysis D: 100mg tpa E: 50mg tpa F: Give all info to patient and let her decide
Question? 34yo lady, 33/40 pregnant. V:Q Significant bilateral PEs. BP 115/78. Tachy 110, 60% O2, RR24, sats 91%. Has had 2/7 full dose LMWH, no better, moved to ICU for closer monitoring A: Continue Fragmin B: iv heparin C: Cather Directed Thrombolysis D: 100mg tpa E: 50mg tpa F: Give all info to patient and let her decide
Summary Advances in diagnostics to enable correct diagnosis at the start Advances in TEAM decisions for the more severe PEs to enable improved morbidity and mortality