1. MANAGEMENT OF PULMONARY EMBOLISM
Dr.Vaijayanti N. Kadam
Attending consultant,
Raheja hospital

2. Management of PE
RISK STRATIFICATION IS THE MOST IMPORTANT FACTOR in managing PE.
KEY PRINCIPLES:
>To assist in planning management,it is important to grade the severity of PE.
>PREDICTION MARKERS MODELS like PULMONARY EMBOLISM SEVERITY INDEX(PESI) is the most extensively validated score.

3. PESI AND SIMPLIFIED PESI SCORE
AGE 1P HISTORY OF CANCER 1P CHRONIC CARDIOPULMONARY DISEASE 1P PULSE 1P CHF 1P SBP<100 1P SAO2 1P 0=LOW RISK;1 OR MORE =HIGH RISK

4. MASSIVE PE(Haemodynamically unstable):
Patients with PE have an approximately 30%mortality rate despite treatment.
If cpr is required ,this increases to 65%.
These patients are the type of patients have the most to benefit from a strategy that includes attempts at urgent embolus destruction ( with thrombolectomy therapy or embolectomy)concurrent haemodynamic support and prevention of further embolisation

5. SUBMASSIVE PE(haemodynamically unstable with evidence of RV DYSFUNCTION)
Patients with PE and evidence of RV dysfunction have a higher mortality (15%) and recurrence rates than normal RV function.
They develop shock and RV thrombi more frequently.
These patients require prevention of further embolisation but also warrant strong consideration of embolus destruction using thrombolytic therapy.

6. MILD PE(Haemodynamically stable with no RV dysfunction)
Patients with PE who have normal BP and normal RV function(determined by ECHO or CTPA scan)have a low risk of death or recurrence.
Predominant management goal is prevention of further embolisation using anticoagulant therapy,as treatment focussed on embolus destruction is unlikely to confer any benefit.

7. EMBOLUS DESTRUCTION:
Intravenous thrombolytic drugs result in dramatic and immediate haemodynamic involvement in some patients by dissolving the embolus and rapidly reducing pulmonary artrial obtruction.
Recommended that once diagnosis is done thrombolytic therapy should be given without delay to patients with massive PE unless contraindicated.

8. RECOMMENDED DOSES OF THROMBOLYTIC DRUGS FOR PE
4400units/kg bolus(over 10 mins)followed by 4400 units/kg per hour for 12 hrs.
units bolus (over 15 mins)followed by units/hr for 24 hrs.
10 MG bolus followed by 90 mg over 2 hrs.
10 units boluses 30 mins apart
UROKINASE
STREPTOKINASE
ALTEPLASE
RETEPLASE

9. ANTICOAGULANT THERAPY:
HEPARIN is known to prevent recurrence and reduce recurrence and reduce the mortality from PE for over 40 yrs.
INTRAVENOUS UNFRACTIONATED HEPARIN.
should be used in patients having renal impairment and following thrombolytic therapy or embolectomy as it can be easily and rapidly reversed.

10. Intravenous unfractionated heparin should be administered after a bolus and initial monitoring should be with 6 hrly activated partial thromboplastin time(aPTT)testing.
Subtherapeutic levels of anticoagulant therapy increases the risk of recurrence,it is important to achieve therapeutic heparinisation rapidly.
Weight based dosing of heparin should be used as target anticoagulation levels are reached sooner.

11. WEIGHT BASED DOSING OF INTRAVENOUS HEPARIN
INITIAL DOSING :LOADING 80 UNITS/KG.
MAINTAINENCE INFUSION 18 UNITS/KG PER HOUR.
PERFORM aPTT in 6 hrs.
SUBSEQUENT DOSE ADJUSTMENTS
APTT dose change u/kg pr hr additional action
<35 secs rebolus of 80u/kg
rebolus of 40u/kg
nil nothing
nothing
> stop infusion for 1 hr

12. LOW MOLECULAR WEIGHT HEPARIN:
Are as effective and safe as unfractionated heparin ,may be even b better.
Longer half life
Increased bioavailability
More predictable dose response
fewer requirements of monitoring and dose adjustments

13. FONDAPARINUX:
is a synthetic pentasaccharide factor Xa inhibitor.similar to LMWH.
Given subcutaneously daily 5mg od
One potential advantage of fondaparinux over LMWH or unfractionated heparin is that the risk of HEPARIN INDUCED THROMBOCYTOPENIA is substantially lower.

14. ORAL ANTICOAGULANTS
ORAL ANTICOAGULANT should be started as soon as possible so that LMWH or unfractionated heparin can be eventually be ceased.
VIT K ANTAGONIST :WARFARIN
NEWER ANTI COAGULANTS:
RIVAROXABAN:(XERALTO) dose 15mg bd for 21 days followed by 20 mg for three months.
DABIGATRAN: dose 110 mg bd dose for three months.

15. IVC FILTERS:Absolute indications
in patients where anticoagulation is contraindicated.
Those whom experience recurrent PE despite adequate anticoagulation.
Complication occuring due to anticoagulation .
Other recommendation :
Patients with extensive dvt.
Patients following a surgical embolectomy .
Patients following thrombolytic therapy.

16. SURGICAL EMBOLECTOMY
PERCUTANEOUS EMBOLECTOMY.
CATHETER DIRECTED THROMBOLYTIC THERAPY
PERCUTANEOUS THROMBUS FRAGMENTATION.

17. THANK YOU