pulmonary embolism treatment protocol.pptx

deals with medical and surgical management of pulmonary embolism

1. PULMONARY EMBOLISM TREATMENT by Dr.vijayakumar

2. Risk stratification , systemic approach, selection and duration of therapy Goals include maintain Spo2 hemodynamic support thrombus propagation & recurrence. Empiric treatment should be started INTRODUCTION

3. UFH iv bolus of 80mg/kg followed by inf of18u/kg/hr Monitor aPTT 6hr after bolus and every 6hrs thereafter targetting 1.5-2.5(upper range) Alt UFH as S.C with no aPTT monitoring at doses of 333U/kg followed by 250U/kg every 12hrs Used in renal failure, late stage preg / conditions req surgery in near term, extremes of weight, recent surgery/trauma/bleed/unstable pt. Drugs

4. Drug of choice Longer half life Achieve early therapeutic conc Reduced bleeding comp No need of monitoring except in antiphospholipid ab baseline elevated aPTT <40kg & >150kg renal insufficiency pregnancy/bleeding/ recurrent thrombosis LMWH

5. Desired Anti Xa levels of 0.4 to 1.0 IU/ml after 4hrs Enox >1.0 Dalt >1.05 Factor Xa inhibitors Fondaparinux a synth pentasacc resembling terminal hep selective for Xa Approved for prophylaxis and in conj with warfarin in Rx of DVT & PE Rivaroxaban direct Xa (oral ) i.v lepirudin (liver) and argatroban indicated in HIT

6. Direct lysis of thrombi Alteplase , streptokinase & urokinase Controversial and inc bleeding comp incl ICH Consider in pt with hemodynamic instability intracavitatory Rt heart thrombi Avoid in isolated Rt vent dysfn Thrombolytic theraphy

7. Catheter fragmentation with local/sys thrombolysis By use of rotating impeller or pressurised N.S the frags are aspirated Risk of paradoxical emboli from frags Should be avoided in pts with intracardiac communications Interventional radio techniques

8. Emergency removal of PE Persistent hypotension Shock Cardiac arrest Failed thrombolysis C.I to thrombolysis Pulmonary embolectomy

9. Heparin and warfarin WARFARIN Vit k antagonist prevents activation of 2,7,9,10, pro C & S. 5-10mg per day Target INR 2-3 done at 3 rd and 5 th day Takes 3 to 5 days to reach efficacy , narrow therap index 5 days of combined war + hep Long term management

10. 3% develop bleeding comps Teratogenic in 1 st and 2 nd trimesters of preg Cholesterol microembolism (purple toes) Strict moniyoring in elderly, malnourished, debilitated pts Renal/liver failure, alcoholics, recent g.i bleeds may increase the risk of bleeding HEPARIN is preferred for long term therapy in malignancy & pregnancy complications

11. Apixaban Dabigatran Aspirin Novel agents

12. A 3 month duration in low risk group Life long Rx in high risk group antiphospholipid syndrome def protein C,S & antithrombin III >2 episodes of recurrence Extended therapy in those with low bleeding risk age >65, male, residual DVT, elev D- dimer at end of RX Duration of therapy

13. Prev surgical ligatures to narrow iumen were done Main ind is C.I for anticoagulants Can be used as prophylaxis Retrrievable or permanent Sig results in imediate period with no sig long term benefits Comps incl dvt , migration,tilt , thrombosis,etc Vena caval filters

14. Currently underutilised Should be utilised unless C.I UFH, LMWH, Xa inhibiyors & warfarin Safe & effective <1% develop comp 4 0-60% reduction in thromboembolism Graduated comp stockings and intermit pneumatic comp stockings No bleeding comp prophylaxsis

15. Thank you