Seminars in respiratory and critical care medicine
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Semin Respir Crit Care Med · Feb 2017
ReviewReversal of Direct Oral Anticoagulants: Current Status and Future Directions.
Direct oral anticoagulants (DOACs) are increasingly used for prevention and treatment of venous thromboembolism and for prevention of stroke in patients with nonvalvular atrial fibrillation. In phase III clinical trials that included more than 100,000 patients, the DOACs were at least as effective as vitamin K antagonists (VKAs) and were associated with less serious bleeding, particularly less intracranial bleeding. Real-world evidence supports these outcomes. ⋯ Anticoagulant reversal should only be considered with life-threatening bleeds, with bleeds that fail to respond to usual measures and in patients requiring urgent surgery. Idarucizumab is licensed for dabigatran reversal and andexanet alfa is likely to be soon licensed for reversal of rivaroxaban, apixaban, and edoxaban. To ensure responsible use of these agents, every hospital needs a bleeding management algorithm that identifies patients eligible for reversal and outlines appropriate dosing regimens.
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Semin Respir Crit Care Med · Feb 2017
ReviewMassive Pulmonary Embolism: Extracorporeal Membrane Oxygenation and Surgical Pulmonary Embolectomy.
Massive pulmonary embolism (PE) refers to large emboli that cause hemodynamic instability, right ventricular failure, and circulatory collapse. According to the 2016 ACCP Antithrombotic Guidelines, therapy for massive PE should include systemic thrombolytic therapy in conjunction with anticoagulation and supportive care. However, in patients with a contraindication to systemic thrombolytics or in those who fail the above interventions, extracorporeal membrane oxygenation (ECMO) and/or surgical embolectomy may be used to improve oxygenation, achieve hemodynamic stability, and successfully treat massive PE. ⋯ Unfortunately, ECMO requires full anticoagulation to maintain the functionality of the system; hence, significant bleeding complicates its use in 35% of patients. Contraindications to ECMO include high bleeding risk, recent surgery or hemorrhagic stroke, poor baseline functional status, advanced age, neurologic dysfunction, morbid obesity, unrecoverable condition, renal failure, and prolonged cardiopulmonary resuscitation without adequate perfusion of end organs. In this review, we discuss management of massive PE, with an emphasis on the potential role for ECMO and/or surgical embolectomy.
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Semin Respir Crit Care Med · Feb 2017
ReviewThrombophilic Evaluation in Patients with Acute Pulmonary Embolism.
Patients with acute pulmonary embolism (PE) are often tested for thrombophilias, which are hereditary and acquired conditions that predispose to thrombosis. If a hereditary condition is identified, then testing is often performed on members of the patient's family. Testing for these conditions can be complex, as the presence of acute thrombosis and antithrombotic therapies can make the results of many tests unreliable. ⋯ Clinicians should carefully consider the relevant risks and benefits before testing patients for thrombophilia. When performed, testing should be timed correctly and care should be taken to properly interpret results. New models that incorporate multiple genetic and clinical markers may improve the utility of testing, but these await further research.
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Semin Respir Crit Care Med · Feb 2017
Echocardiography in the Risk Assessment of Acute Pulmonary Embolism.
Acute pulmonary embolism (PE) is a major cause of morbidity and mortality and is classified as massive (high risk), submassive (intermediate risk), or nonmassive (low risk) based on the hemodynamic status and clinical characteristics of the patient. At this time, the management of patients with submassive PE remains controversial and approaches for improving risk assessment are critical. ⋯ Because of their reproducibility and objective nature, quantitative RV echocardiographic assessments have been gaining importance in the assessment of acute PE. Current limitations to the use of echocardiography for risk assessment in acute PE are the lack of normative values for RV parameters, the absence of standardization of measurements across different ultrasound platforms, and the heterogeneity of the performance of echocardiographic examinations and reports across centers.