Seminars in respiratory and critical care medicine
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Semin Respir Crit Care Med · Feb 2017
ReviewApproach to Suspected Acute Pulmonary Embolism: Should We Use Scoring Systems?
Modern diagnostic strategies for pulmonary embolism diagnosis almost all rely on an initial assessment of the pretest probability. Clinical prediction rules are decision-making tools using combinations of easily available clinical predictors to define the probability of a disease. ⋯ They should be derived and validated following strict methodological standards. The use of clinical prediction rules should be encouraged, since their implementation in local guidelines for pulmonary embolism diagnosis has been shown to improve patients' outcomes.
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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.