Intensive Care Treatment of Pulmonary Embolism: An Update Based on the Revised AWMF S2k Guideline

 

 Permissions and Reprints

Abstract

Acute pulmonary embolism (PE) remains a significant cause of morbidity and requires prompt diagnosis and management. The prognosis of affected patients depends on the clinical severity. Therefore, risk stratification is imperative for therapeutic decision-making. Patients with high-risk PE need intensive care. These include patients who have successfully survived resuscitation, with obstructive shock or persistent haemodynamic instability. Bedside diagnostics by means of sonographic procedures are of outstanding importance in this high-risk population. In addition to the treatment of hypoxaemia with noninvasive and invasive techniques, the focus is on drug-based haemodynamic stabilisation and usually requires the elimination or reduction of pulmonary vascular thrombotic obstruction by thrombolysis. In the event of a contraindication to thrombolysis or failure of thrombolysis, various catheter-based procedures for thrombus extraction and local thrombolysis are available today and represent an increasing alternative to surgical embolectomy. Mechanical circulatory support systems can bridge the gap between circulatory arrest or refractory shock and definitive stabilisation but are reserved for centres with the appropriate expertise. Therapeutic strategies for patients with intermediate- to high-risk PE in terms of reduced-dose thrombolytic therapy or catheter-based procedures need to be further evaluated in prospective clinical trials.

Publication History

Received: 24 September 2023

Accepted: 27 September 2023

Article published online:
18 March 2024

© 2024. Thieme. All rights reserved.

Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany

• References

• 1 Wendelboe AM, Raskob GE. Global burden of thrombosis: epidemiologic aspects. Circ Res 2016; 118 (09) 1340-1347
  CrossrefPubMedGoogle Scholar
• 2 Delmas C, Aissaoui N, Meneveau N. et al. Reperfusion therapies in pulmonary embolism-state of the art and expert opinion: a position paper from the “Unité de Soins Intensifs de Cardiologie” group of the French Society of Cardiology. Arch Cardiovasc Dis 2020; 113 (11) 749-759
  CrossrefPubMedGoogle Scholar
• 3 Wärntges S, Konstantinides SV. Progress in the management of acute pulmonary embolism. Curr Opin Pulm Med 2015; 21 (05) 417-424
  CrossrefPubMedGoogle Scholar
• 4 Konstantinides SV, Meyer G, Becattini C. et al; ESC Scientific Document Group. 2019 ESC guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS). Eur Heart J 2020; 41 (04) 543-603
  CrossrefPubMedGoogle Scholar
• 5 Linnemann B, Blank W, Doenst T. et al. Diagnostics and Therapy of Venous Thrombosis and Pulmonary Embolism. The revised AWMF S2k Guideline. Vasa 2023 Oct; 52(S111): 1–146. PMID: 37904504. DOI: 10.1024/0301-1526/a001089
  PubMedGoogle Scholar
• 6 Ghanem A, Andrassy M, Dürschmied D. et al. Interventional treatment and multidisciplinary management strategies for acute pulmonary embolism. Kardiologe 2023; 17 (03) 141-159
  CrossrefPubMedGoogle Scholar
• 7 Raskob GE, Angchaisuksiri P, Blanco AN. et al; ISTH Steering Committee for World Thrombosis Day. Thrombosis: a major contributor to global disease burden. Arterioscler Thromb Vasc Biol 2014; 34 (11) 2363-2371
  CrossrefPubMedGoogle Scholar
• 8 Keller K, Hobohm L, Ebner M. et al. Trends in thrombolytic treatment and outcomes of acute pulmonary embolism in Germany. Eur Heart J 2020; 41 (04) 522-529
  CrossrefPubMedGoogle Scholar
• 9 Barco S, Mahmoudpour SH, Valerio L. et al. Trends in mortality related to pulmonary embolism in the European Region, 2000-15: analysis of vital registration data from the WHO Mortality Database. Lancet Respir Med 2020; 8 (03) 277-287
  CrossrefPubMedGoogle Scholar
• 10 Harjola VP, Mebazaa A, Čelutkienė J. et al. Contemporary management of acute right ventricular failure: a statement from the Heart Failure Association and the Working Group on Pulmonary Circulation and Right Ventricular Function of the European Society of Cardiology. Eur J Heart Fail 2016; 18 (03) 226-241
  CrossrefPubMedGoogle Scholar
• 11 Helms J, Carrier M, Klok FA. High-risk pulmonary embolism in the intensive care unit. Intensive Care Med 2023; 49 (05) 579-582
  CrossrefPubMedGoogle Scholar
• 12 Pizarro C, Hammerstingl C, Schaefer C, Grohé C, Nickenig G, Skowasch D. [New therapeutic approaches to pulmonary embolism: trials' results and significance of direct oral anticoagulants]. Pneumologie 2015; 69 (02) 99-110
  PubMedGoogle Scholar
• 13 Hecker M, Sommer N, Hecker A. et al. Lungenembolie. Med Klin Intensivmed Notf Med 2016; 111 (02) 163-175 , quiz 176–177
  CrossrefPubMedGoogle Scholar
• 14 Konstantinides SV, Meyer G. The 2019 ESC guidelines on the diagnosis and management of acute pulmonary embolism. Eur Heart J 2019; 40 (42) 3453-3455
  CrossrefPubMedGoogle Scholar
• 15 Konstantinides S, Geibel A, Kasper W, Olschewski M, Blümel L, Just H. Patent foramen ovale is an important predictor of adverse outcome in patients with major pulmonary embolism. Circulation 1998; 97 (19) 1946-1951
  CrossrefPubMedGoogle Scholar
• 16 Becattini C, Vedovati MC, Agnelli G. Prognostic value of troponins in acute pulmonary embolism: a meta-analysis. Circulation 2007; 116 (04) 427-433
  CrossrefPubMedGoogle Scholar
• 17 Stadlbauer A, Philipp A, Blecha S. et al. Long-term follow-up and quality of life in patients receiving extracorporeal membrane oxygenation for pulmonary embolism and cardiogenic shock. Ann Intensive Care 2021; 11 (01) 181
  CrossrefPubMedGoogle Scholar
• 18 Hobohm L, Farmakis IT, Keller K. et al. Pulmonary embolism response team (PERT) implementation and its clinical value across countries: a scoping review and meta-analysis. Clin Res Cardiol 2023; 112 (10) 1351-1361
  CrossrefPubMedGoogle Scholar
• 19 Fleitas Sosa D, Lehr AL, Zhao H. et al. Impact of pulmonary embolism response teams on acute pulmonary embolism: a systematic review and meta-analysis. Eur Respir Rev 2022; 31 (165) 220023
  CrossrefPubMedGoogle Scholar
• 20 Gottlieb J, Capetian P, Hamsen U. et al. German S3 guideline: oxygen therapy in the acute care of adult patients. Respiration 2022; 101 (02) 214-252
  CrossrefPubMedGoogle Scholar
• 21 Rosenberger P, Shernan SK, Shekar PS. et al. Acute hemodynamic collapse after induction of general anesthesia for emergent pulmonary embolectomy. Anesth Analg 2006; 102 (05) 1311-1315
  CrossrefPubMedGoogle Scholar
• 22 Bennett JM, Pretorius M, Ahmad RM, Eagle SS. Hemodynamic instability in patients undergoing pulmonary embolectomy: institutional experience. J Clin Anesth 2015; 27 (03) 207-213
  CrossrefPubMedGoogle Scholar
• 23 Francis S, Kabrhel C. Current controversies in caring for the critically ill pulmonary embolism patient. Emerg Med Clin North Am 2020; 38 (04) 931-944
  CrossrefPubMedGoogle Scholar
• 24 Monnet X, Marik P, Teboul JL. Passive leg raising for predicting fluid responsiveness: a systematic review and meta-analysis. Intensive Care Med 2016; 42 (12) 1935-1947
  CrossrefPubMedGoogle Scholar
• 25 Monnet X, Teboul JL. Passive leg raising: five rules, not a drop of fluid!. Crit Care 2015; 19 (01) 18
  CrossrefPubMedGoogle Scholar
• 26 Kholdani CA, Fares WH. Management of right heart failure in the intensive care unit. Clin Chest Med 2015; 36 (03) 511-520
  CrossrefPubMedGoogle Scholar
• 27 Uhlig K, Efremov L, Tongers J. et al. Inotropic agents and vasodilator strategies for the treatment of cardiogenic shock or low cardiac output syndrome. Cochrane Database Syst Rev 2020; 11 (11) CD009669
  PubMedGoogle Scholar
• 28 Karami M, Mandigers L, Miranda DDR. et al; DUTCH ECLS Study Group. Survival of patients with acute pulmonary embolism treated with venoarterial extracorporeal membrane oxygenation: a systematic review and meta-analysis. J Crit Care 2021; 64: 245-254
  CrossrefPubMedGoogle Scholar
• 29 Zuo Z, Yue J, Dong BR, Wu T, Liu GJ, Hao Q. Thrombolytic therapy for pulmonary embolism. Cochrane Database Syst Rev 2021; 4 (04) CD004437
  PubMedGoogle Scholar
• 30 Konstantinides S. Clinical practice. Acute pulmonary embolism. N Engl J Med 2008; 359 (26) 2804-2813
  CrossrefPubMedGoogle Scholar
• 31 Meyer G, Vicaut E, Danays T. et al; PEITHO Investigators. Fibrinolysis for patients with intermediate-risk pulmonary embolism. N Engl J Med 2014; 370 (15) 1402-1411
  CrossrefPubMedGoogle Scholar
• 32 Marti C, John G, Konstantinides S. et al. Systemic thrombolytic therapy for acute pulmonary embolism: a systematic review and meta-analysis. Eur Heart J 2015; 36 (10) 605-614
  CrossrefPubMedGoogle Scholar
• 33 Chatterjee S, Chakraborty A, Weinberg I. et al. Thrombolysis for pulmonary embolism and risk of all-cause mortality, major bleeding, and intracranial hemorrhage: a meta-analysis. JAMA 2014; 311 (23) 2414-2421
  CrossrefPubMedGoogle Scholar
• 34 Sanchez O, Charles-Nelson A, Ageno W. et al; PEITHO-3 Investigators. Reduced-dose intravenous thrombolysis for acute intermediate-high-risk pulmonary embolism: rationale and design of the Pulmonary Embolism International THrOmbolysis (PEITHO)-3 trial. Thromb Haemost 2022; 122 (05) 857-866
  Article in Thieme ConnectPubMedGoogle Scholar
• 35 Ishisaka Y, Watanabe A, Fujisaki T. et al. Comparison of interventions for intermediate to high-risk pulmonary embolism: a network meta-analysis. Catheter Cardiovasc Interv 2023; 102 (02) 249-265
  CrossrefPubMedGoogle Scholar
• 36 Harvey JJ, Huang S, Uberoi R. Catheter-directed therapies for the treatment of high risk (massive) and intermediate risk (submassive) acute pulmonary embolism. Cochrane Database Syst Rev 2022; 8 (08) CD013083
  PubMedGoogle Scholar
• 37 Lee T, Itagaki S, Chiang YP, Egorova NN, Adams DH, Chikwe J. Survival and recurrence after acute pulmonary embolism treated with pulmonary embolectomy or thrombolysis in New York State, 1999 to 2013. J Thorac Cardiovasc Surg 2018; 155 (03) 1084-1090.e12
  CrossrefPubMedGoogle Scholar
• 38 Keeling WB, Sundt T, Leacche M. et al; SPEAR Working Group. Outcomes after surgical pulmonary embolectomy for acute pulmonary embolus: a multi-institutional study. Ann Thorac Surg 2016; 102 (05) 1498-1502
  CrossrefPubMedGoogle Scholar
• 39 Pasrija C, Kronfli A, Rouse M. et al. Outcomes after surgical pulmonary embolectomy for acute submassive and massive pulmonary embolism: a single-center experience. J Thorac Cardiovasc Surg 2018; 155 (03) 1095-1106.e2
  CrossrefPubMedGoogle Scholar
• 40 Loyalka P, Ansari MZ, Cheema FH, Miller III CC, Rajagopal S, Rajagopal K. Surgical pulmonary embolectomy and catheter-based therapies for acute pulmonary embolism: a contemporary systematic review. J Thorac Cardiovasc Surg 2018; 156 (06) 2155-2167
  CrossrefPubMedGoogle Scholar
• 41 Giri J, Sista AK, Weinberg I. et al. Interventional therapies for acute pulmonary embolism: current status and principles for the development of novel evidence: a scientific statement from the American Heart Association. Circulation 2019; 140 (20) e774-e801
  CrossrefPubMedGoogle Scholar
• 42 Weinstein T, Deshwal H, Brosnahan SB. Advanced management of intermediate-high risk pulmonary embolism. Crit Care 2021; 25 (01) 311
  CrossrefPubMedGoogle Scholar
• 43 Becattini C, Agnelli G, Lankeit M. et al. Acute pulmonary embolism: mortality prediction by the 2014 European Society of Cardiology risk stratification model. Eur Respir J 2016; 48 (03) 780-786
  CrossrefPubMedGoogle Scholar