Pulmonary Embolism

Jeannette Corona

Title: Alteplase Treatment 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

Journal Article

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

Pulmonary Embolism-Overview

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).

Summary of Article

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

Classifications of Acute PE

ImmobilizationHypertension AtherosclerosisHistory of Heavy SmokingObesityTrauma or surgeryMalignant Neoplasms

Major Risk Factors 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

Classic Signs and Symptoms 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

Treatment of PE

Alteplase initiates 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 (lysis of 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

Alteplase

Treatment for Acute 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 Alteplase for treatment of submassive PE

Among patients with submassive PE, those who received Heparin plus Alteplase had 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 Alteplase were not significant

Treatment of Submassive PE

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 Alteplase and 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 Alteplase is an “off-label” use of the drug. When used in CDT, Alteplase has 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

Summary of Article

Patients receiving Alteplase for 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

Relevance to Critical Care Nursing

1.What is the gold standard for diagnosis of a Pulmonary Embolism?

2. Which vein is the most common source of thrombi that become a pulmonary embolism?

Questions

1. Pulmonary Angiography

2. Iliofemoral vien

Answers

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

References