Nihon Geka Gakkai zasshi
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Nihon Geka Gakkai zasshi · Mar 2005
Review[Pulmonary embolectomy for acute massive pulmonary thromboembolism].
Acute pulmonary thromboembolism is a frequently lethal and acute-onset in-hospital complication after surgery. Absolute indications for surgical embolectomy are acute massive pulmonary embolism with deep shock, refractory circulatory collapse, and continuous hypoxemia. Although thrombolytic therapy is indicated for patients with pulmonary thromboembolism with right ventricular overload, it is contraindicated for patients after major surgery or with stroke due to the high risk of rebleeding. ⋯ Pulmonary embolectomy relieves the right ventricular overload, and immediate restoration of right ventricular function contributes to the recovery of hemodynamics. A recent study revealed improved outcome for massive pulmonary embolism with early diagnosis with multidetector-row computed tomography, risk stratification using echocardiography, and surgical embolectomy. Surgical pulmonary thromboembolectomy should be considered for critically ill patients with massive pulmonary thromboembolism.
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Nihon Geka Gakkai zasshi · Mar 2005
Review[Therapy of acute pulmonary thromboembolism from the physician's standpoint].
The therapy of acute pulmonary thromboembolism (APTE) is based on the clinical grade and ranges from ambulant therapy with anticoagulation, to thrombolysis, inferior vena cava (IVC) filtration, and catheter thrombectomy. In the absence of contraindications, initial treatment of APTE should consist of parenteral anticoagulation with unfractionated heparin. Long-term anticoagulation therapy, usually with warfarin, should be administered according to the individual risk profile of the patient. ⋯ Relative indications for IVC filters that require individualized decision making include proximal DVT, especially with free-floating thrombi or in patients with limited cardiopulmonary reserve. For patients with massive APTE with contraindications to anticoagulation or in whom anticoagulation is uneffective, transcatheter aspiration with catheterization or fragmentation using a guidewire and rotating pig-tail catheter can be used. In addition, cardiopulmonary management such as supplemental oxygen, catecholamine administration, percutaneous cardiopulmonary support, etc. may be necessary for individual patients.
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Blood transfusion against surgical patients is mainly as a replacement therapy for intra-operative bleeding. Transfusion trigger depends on to maintain 12 ml/kg/min oxygen carrying capacity. Oxygen consumption depends on oxygen carrying capacity which multiplicity hemoglobin concentration and cardiac output. ⋯ Dilution coagulopathy due to massive bleeding exceed one blood volume is the main indication of plasma and platelet transfusion. It is necessary to administrate fresh frozen plasma for replenishing coagulation function with 30% of one body plasma volume when prothrombin time prolong more than 16 seconds. Platelet transfusion is effective for hemostasis in case of massive bleeding which exceed 1.5 blood volume and also peripheral blood platelet count indicate lower than 50,000/mm3.