Pulmonary Embolism

1. Pulmonary Embolism Jeannette Corona

2. Journal Article • Title: AlteplaseTreatment of Acute Pulmonary Embolism in the Intensive Care Unit • Authors: Pamela L. Smithburger, PharmD, BCPS, Shuana Campbell, MSN, and Sandra L. Kane-Gill, MS, PharmD, MSC • Journal: Critical Care Nurse • Published: April 2013

3. Pulmonary Embolism-Overview • Pulmonary embolism (PE) is a blockage of one or more of the pulmonary arteries by fat, air, blood clot or tumor cells. • S/S range from asymptomatic to massive PE • Mortality rate averages from 10-15%, but can be as high as 60% if patient is in hemodynamic shock • PE is the third leading cause of death among hospitalized patients in the United States • 44% of patients who have PE have a confirmed deep vein thrombosis • Thrombi from the iliofemoral vein are the most common source of pulmonary embolisms

4. Summary of Article • Problem: The presentation of PE is a wide spectrum of clinical manifestations, ranging from massive pulmonary embolism to small peripheral emboli. • Purpose: For critical care nurses to be able to identify and treat patients according to their signs and symptoms is crucial when an acute embolism is suspected: also reviews classifications of Acute PE, explains treatment, and review assessment of literature evaluating Alteplase (drug).

5. Classifications of Acute PE • The American Heart Association has gone a step further to define Acute PE into three categories to aid in treatment selection • Massive: Acute pulmonary embolism with Sustained hypotension (systolic blood pressure <90 mm Hg for at least 15 min) Requirement for inotropic support, not because of other causes. Persistent or pulseless, bradycardia (heart rate <40/min) with shock. • Submassive: Acute pulmonary embolism with myocardial necrosis or right ventricular dysfunction but no systemic hypotension. • Low Risk: Acute pulmonary embolism with normal levels of biomarkers, no systemic hypotension or right ventricular dysfunction

6. Major Risk Factors of PE • Immobilization • Hypertension • Atherosclerosis • History of Heavy Smoking • Obesity • Trauma or surgery • Malignant Neoplasms

7. Classic Signs and Symptoms of PE • dyspnea at rest or with exertion (73%) • sharp chest pain that may radiate to the shoulder (44%) • calf or thigh pain (44%) • calf or thigh swelling (41%) • cough (34%) • 2+ pillow orthopnea (28%) • wheezing (21%) • Gold Standard for diagnosis of a PE is pulmonary angiography

8. Treatment of PE • Initial Treatment • Stabilization of hemodynamic status • Hypoxemia: give patient oxygen • Hypotension: fluid boluses are used initially to replace fluids; vasopressors are given if fluid replacement is inadequate • Anticoagulation: give patients anticoagulation therapy with low-molecular- weight heparin unless contraindicated

9. Alteplase • Alteplaseinitiates local fibrinolysis by binding to the fibrin in a clot and converting the trapped plasminogen to plasmin that results in the dissolution of a thrombus • When administered, more than 50% of the drug concentration in the plasma is cleared within 5 minutes after the infusion is completed • Originally, Food Drug and Administration (FDA) approved Alteplase as a thrombolytic agent for management of ST-elevation myocardial infarction (lysisof thrombi in coronary arteries), acute stroke, and acute pulmonary embolism • In 2002, the FDA also approved Alteplase for management of acute PE with unstable hemodynamic status

10. Treatment for Acute PE

11. Treatment of Submassive PE • Administration of a thrombolytic agent in addition to heparin requires assessment of a patient’s characteristics and of the risks and benefits of thrombolytic use, such as right ventricular strain and predisposition for bleeding • The FDA has not approved the use of Alteplasefor treatment of submassivePE • Among patients with submassivePE, those who received Heparin plus Alteplasehad less deterioration in clinical status, shorter hospital stays, an increase in pulmonary perfusion, shorter time to improved right ventricular function, and lower hospital mortality than those who received Heparin alone • Differences in bleeding between patients who received heparin alone and patients who received heparin plus Alteplasewere not significant

12. Summary of Article • Results of the clinical trials and assessments of the efficacy of catheter-directed thrombolysis (CDT) with Alteplase: • With CDT, Alteplase can be delivered directly to the thrombus at a high concentration • Lower doses of a Alteplaseand shorter durations of infusions are used to achieve complete thrombolysis • The use of lower doses and shorter infusions times with Alteplase reduces the risk of bleeding complications • Currently, CDT with Alteplaseis an “off-label” use of the drug. When used in CDT, Alteplasehas been infused at 0.5 to 1 mg/h for up to 48 hours • In conclusion, the evidence of any benefit from the use of Alteplase accompanied with Heparin in the treatment of acute PE is insufficient

13. Relevance to Critical Care Nursing • Patients receiving Alteplasefor the treatment of acute PE require specific nursing monitoring and care • Monitor closely for bleeding and hypertension after administration of Alteplase • Monitor HR, BP, and LOC • Neurological checks should be completed every 15 min- utes during administration of the drug, then every 30 minutes for 6 hours, and then hourly for 24 hours after initial treatment • Alert patient to report any changes in headache, vision, and sensorium

14. Questions • What is the gold standard for diagnosis of a Pulmonary Embolism? • Which vein is the most common source of thrombi that become a pulmonary embolism?

15. Answers • Pulmonary Angiography • Iliofemoralvien

16. References • Smithburger, P. L., Campbell, S., & Kane-Gill, S. L. (2013). Alteplase Treatment of Acute Pulmonary Embolism in the Intensive Care Unit. Critical Care Nurse, 33(2), 17-27. doi:10.4037/ccn2013626