Presentation on theme: "Mike Demeo Nikhil Kapila April 11, 2014"— Presentation transcript:
1Mike Demeo Nikhil Kapila April 11, 2014 Critical Care M&MMike DemeoNikhil KapilaApril 11, 2014
2Morbidity & Mortality Conference It is for the department faculty and residents to peer review case(s) from the inpatient service.The primary objective is to improve overall patient care focusing on quality of care delivered, performance improvement, patient safety and risk management.This material is confidential and is utilized as defined in Connecticut State statute 19a-17b Section(4) for evaluating and improving the quality of health care rendered
3Morbidity & Mortality Conference Goals:To review recent cases and identify areas for improvement for (all) clinicians involvedPatient complications & deaths are reviewed with the purpose of educating staff, residents and medical students.To identify ‘system issues’, which negatively affect patient careTo modify behavior and judgment and to prevent repetition of errors leading to complications.To assess all six ACGME competencies and Institute of Medicine (IOM) Values in the quality of care deliveredConferences are non punitive and focus on the goal of improved and safer patient careThis material is confidential and is utilized as defined in Connecticut State statute 19a-17b Section(4) for evaluating and improving the quality of health care rendered
4Morbidity & Mortality Conference Every Defect is a TreasureThis material is confidential and is utilized as defined in Connecticut State statute 19a-17b Section(4) for evaluating and improving the quality of health care rendered
5Every Defect is a Treasure Errors are due to:Processes – 80%Individuals – 20%Translate all error into educationThis material is confidential and is utilized as defined in Connecticut State statute 19a-17b Section(4) for evaluating and improving the quality of health care rendered
6Learning Objectives-What is the role for DVT prophylaxis in patients with recent intracranial hemorrhage?What are the roles of thrombolytics and heparin in the management of PE?What are the other options in treating PE?EmbolectomyEKOS
7VTE in patients with a history of ICH DVT has been reported in 2-15% of patients with ICHPE occurs in 1-5% of patientsUsually 2-4 weeks after onset of acute ICHRisk factors for VTE in patients with h/o ICHStroke severityWeakness/changes in level of consciousnessFemale sexAfrican Americans
8Venous Thromboembolism Prevention in the Setting of Acute/Recent Intracranial Hemorrhage
10VTE Prevention -Intermittent Pneumatic Compression Treatment with IPC devices are associated with lower rate of DVTShould be instituted immediatelyCLOTS 3 TrialOpen label, randomized study2876 patients with stroke. 322 with hemorrhagic strokeIPC use was associated with reduced risk of DVT at 30 days-6.7 % vs 17%No major adverse eventsIPC devices are associated with a greater incidence of skin breaks
13VTE Prevention-Anticoagulation Meta-analysis of four studiesCompared anticoagulation therapy with other treatments in patients with ICHUse of anti-coagulation was associated with a significant reduction in Pulmonary Embolism (1.7% vs 2.9% P=0.01)Use of anti-coagulation was associated with a non-significant reduction in DVT formation and mortalityNon-significant increase in hematoma enlargementAHA/American Stroke Association:“After documentation of cessation of bleeding, low dose subcutaneous low molecular-weight heparin or unfractionated heparin may be considered for prevention of venous thromboembolism in patients with lack of mobility after 1 to 4 days from onset”
14Anticoagulation and Thrombolytics in the Management of PE
15Initial Anticoagulation in PE Subcutaneous LMWHSubcutaneous FondaparinuxIntravenous UFH
16Initial Anticoagulation in PE SC Low Molecular Weight Heparin (LMWH):Now considered better initial agent over UFH for most hemodynamically stable patients.Secondary to multiple randomized trials and meta-analyses showing:Lower mortalityFewer recurrent thromboembolic eventsLess major bleeding eventsNon-superior to Fondaparinux.Monitoring: none required in most patients.
17Initial Anticoagulation in PE SC Fondaparinux:Recommended for most hemodynamically stable patients.Based on multiple studies against IV UFH:Same effects on mortality, recurrent thromboembolism, major bleeding.Advantages over IV UFH:Once or twice daily administrationFixed doseLess thrombocytopeniaNo monitoring necessary in most patients
18Initial Anticoagulation in PE IV Unfractionated Heparin (IV UFH):No longer preferred agent for stable acute PE.Preferred Indications:Persistent hypotensionIncreased risk of bleedingThrombolysis being consideredConcern about subcutaneous absorptionRenal failureObese patientsMonitoring:aPTT
19Role of Thrombolytics in PE Agents:tPA:Naturally occurring enzymeBinds fibrin to enhance plasminogen activationStreptokinase:Polypeptide derived from beta-hemolytic strepBinds to plasminogen to activate plasminUrokinase:Occurs naturally in urinePlasminogen activator
20Role of Thrombolytics in PE Indications:Persistent hypotension <90 mmHg SBP or decrease in SBP >/= 40mmHg from baseline.Potential Indications:Severe hypoxemiaLarge V/Q mismatchExtensive clot burdenRV dysfunctionFree-floating atrial/ventricular thrombusPFOCardiopulmonary Resuscitation
22Role of Thrombolytics in PE Purpose : Compare echo parameters and clinical outcome of heparin vs thrombolysis in first 180 days after SPE w/ RVD.Methods: 72 consecutive patients w/ first episode SPE and symptoms <6 hours w/ CT proven PE and echo proven RVD.Results: Thrombolysis group showed significant early improvement in RV function and this improvement was still observed through the 180 day follow up. Also noted to significant reduction in clinical events during hospitalization.
27Embolectomy in PE Embolectomy: Should be considered when patient presentation warrants thrombolysis but therapy either fails or is contraindicated.Can be done surgically or via catheter:Dependent upon availabilities and expertise at each individual institution.
28Embolectomy in PE Surgical Embolectomy: Requires cardiopulmonary bypass.Has been prompted by:failure of initial thrombolysisecho evidence of thrombus in:R atriumR ventriclePFOCardiac arrest pre-surgery can be predictive of mortality during surgery by one small study of 55 pts:97% survival of those w/o75% survival of those w/
29Embolectomy in PE Catheter Embolectomy: Rheolytic (ie. AngioJet): Injection of pressurized saline to macerate emboli. Fragments collected via exhaust lumen.Requires venous cut down.Rotational:Cardiac catheter equipped with a rotating device that continuously fragments/aspirates pieces of the thrombus.Does not require venous cut down.Suction:Uses a large lumen catheter to apply direct negative pressure suction w/ an aspiration syringe.Fragmentation:Thrombus disruption via manually rotating a standard pigtail catheter or balloon angio catheter against the thrombus.
32Advanced Interventions: Catheter Directed Intervention Indications for catheter based intervention in the setting of acute massive PE should include one of the followingArterial hypotension. defined as systolic arterial pressure ≤ 90 mm Hg, a drop in systolic arterial pressure ≥ 40 mm Hg for ≥ 15 minutes, or ongoing administration of catecholamine for the treatment of systemic arterial hypotension;Cardiogenic shock with peripheral hypoperfusion and hypoxia;Circulatory collapse, including syncope or need for cardiopulmonary resuscitation;Echocardiographic findings indicating right ventricular dilatation and/or pulmonary hypertension;Subtotal or total filling defect in the left and/or right main pulmonary artery determined by chest computed tomography (CT) scan or by conventional pulmonary angiography; orWidened arterial-alveolar O2 gradient (> 50 mm Hg).
34Advanced Interventions: Catheter Directed Intervention Meta-analysis examining 594 patients from 35 studiesPatients with acute massive PE treated with modern CDTClinical success defined as stabilization of hemodynamics, resolution of hypoxia, and survivalPooled clinical success rate of CDI was 86.5%Risk of minor and major complications were 7.9% and 2.4% respectively
35Advanced Interventions-EKOS Ultrasound accelerated catheter directed thrombolysisDelivered via an infusion catheter that emits ultrasound energy to accelerate the thrombolytic cascadeThis is achieved by using the EkoSonic Endovascular System that is manufactured by the EKOS corporationAcoustic energy leads to breakdown of fibrin and increases fibrin porosity without causing distal embolizationThis facilitates penetration of thrombolytic drugs
37Advanced Interventions-EKOS Patients were randomized into EKOS group and conventional CDI group who received either tPA or urokinaseComplete thrombolysis: More than 90% thrombus removalNear complete lysis: 75-90% removal of thrombusPartial lysis: 50-75% removalFollow-up pulmonary angiography performed hours after initiation of intervention to determine progression of thrombus disruption
40Advanced Interventions-EKOS 59 patients with acute main or lower lobe PE and RV/LV ratio of >1Randomized to receive either ultrasound assisted catheter directed thrombolysis vs. unfractionated heparin alonePrimary outcome was the difference in RV/LV ratio from baseline to 24 hoursSafety outcomes included death, major or minor bleeding, and recurrent VTE at 90 days
42Advanced Interventions-EKOS Significant reduction in RV/LV ratio in study groupSignificant reduction in pulmonary artery and right atrial pressuresSignificant increase in cardiac indexNo recurrent VTE or hemodynamic decompensationNo major bleeding complications. 3 patients (10%) experienced minor bleeding complications
46ReferencesOgata T, Yasaka M, Wakugawa Y, Inoue T, Ibayashi S, Okada Y. Deep venous thrombosis after acute intracerebral hemorrhage. J Neurol Sci. 2008;272(1-2):83 Christensen MC, Dawson J, Vincent C. Risk of thromboembolic complications after intracerebral hemorrhage according to ethnicity. Adv Ther. 2008;25(9):831.Skaf E, Stein PD, Beemath A, Sanchez J, Bustamante MA, Olson RE. Venous thromboembolism in patients with ischemic and hemorrhagic stroke. Am J Cardiol. 2005;96(12):1731.Orken DN, Kenangil G, Ozkurt H, Guner C, Gundogdu L, Basak M, Forta H. Prevention of deep venous thrombosis and pulmonary embolism in patients with acute intracerebral hemorrhage. Neurologist ;15(6):329.CLOTS (Clots in Legs Or sTockings after Stroke) Trials Collaboration, Dennis M, Sandercock P, Reid J, Graham C, Forbes J, Murray G. Effectiveness of intermittent pneumatic compression in reduction of risk of deep vein thrombosis in patients who have had a stroke (CLOTS 3): a multicentre randomised controlled trial. Lancet ;382(9891):516.Paciaroni M, Agnelli G, Venti M, Alberti A, Acciarresi M, Caso V. Efficacy and safety of anticoagulants in the prevention of venous thromboembolism in patients with acute cerebral hemorrhage: a meta-analysis of controlled studies. J Thromb Haemost. 2011;9(5):893