Transcript Case Presentation

Critical Care M&M
Mike Demeo
Nikhil Kapila
April 11, 2014
Morbidity & Mortality Conference

It is for the department faculty and residents to peer review
case(s) from the inpatient service.

The primary objective is to improve overall patient care focusing
on quality of care delivered, performance improvement, patient
safety and risk management.

This material is confidential and is utilized as defined in Connecticut State statute 19a-17b Section(4) for evaluating and improving the quality of health care
rendered
Morbidity & Mortality Conference
Goals:
To
review recent cases and identify areas for improvement for (all) clinicians involved
Patient complications & deaths are reviewed with the purpose of educating staff, residents
and medical students.
To identify ‘system issues’, which negatively affect patient care
To modify behavior and judgment and to prevent repetition of errors leading to
complications.
To assess all six ACGME competencies and Institute of Medicine (IOM) Values in the
quality of care delivered
Conferences are non punitive and focus on the goal of improved and safer patient care
This material is confidential and is utilized as defined in Connecticut State statute 19a-17b Section(4) for evaluating and improving the quality of health care rendered
Morbidity & Mortality Conference
Every Defect is a Treasure
This material is confidential and is utilized as defined in Connecticut State statute 19a-17b Section(4) for evaluating and improving the
quality of health care rendered
Every Defect is a Treasure
Errors are due to:
Processes – 80%
Individuals – 20%
Translate all error into education
This material is confidential and is utilized as defined in Connecticut State statute 19a-17b Section(4) for evaluating and improving the quality of health care rendered
Learning Objectives1.
What is the role for DVT prophylaxis in patients with
recent intracranial hemorrhage?
2.
What are the roles of thrombolytics and heparin in the
management of PE?
3.
What are the other options in treating PE?
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Embolectomy
EKOS
VTE in patients with a history of ICH
 DVT has been reported in 2-15% of patients with ICH
 PE occurs in 1-5% of patients
 Usually 2-4 weeks after onset of acute ICH
 Risk factors for VTE in patients with h/o ICH
 Stroke severity
 Weakness/changes in level of consciousness
 Female sex
 African Americans
Venous Thromboembolism Prevention
in the Setting of Acute/Recent
Intracranial Hemorrhage
VTE Prevention
VTE Prevention
-Intermittent Pneumatic Compression
 Treatment with IPC devices are associated with lower rate of
DVT
 Should be instituted immediately
 CLOTS 3 Trial
 Open label, randomized study
 2876 patients with stroke. 322 with hemorrhagic stroke
 IPC use was associated with reduced risk of DVT at 30 days-6.7 % vs
17%
 No major adverse events
 IPC devices are associated with a greater incidence of skin breaks
VTE Prevention
VTE Prevention-Anticoagulation
VTE Prevention-Anticoagulation
 Meta-analysis of four studies
 Compared anticoagulation therapy with other treatments in patients
with ICH
 Use of anti-coagulation was associated with a significant reduction in
Pulmonary Embolism (1.7% vs 2.9% P=0.01)
 Use of anti-coagulation was associated with a non-significant
reduction in DVT formation and mortality
 Non-significant increase in hematoma enlargement
 AHA/American Stroke Association:
 “After documentation of cessation of bleeding, low dose subcutaneous
low molecular-weight heparin or unfractionated heparin may be
considered for prevention of venous thromboembolism in patients
with lack of mobility after 1 to 4 days from onset”
Anticoagulation and Thrombolytics
in the Management of PE
Initial Anticoagulation in PE
 Subcutaneous LMWH
 Subcutaneous Fondaparinux
 Intravenous UFH
Initial Anticoagulation in PE
SC Low Molecular Weight Heparin (LMWH):
 Now considered better initial agent over UFH for most
hemodynamically stable patients.
 Secondary to multiple randomized trials and meta-analyses showing:
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Lower mortality
Fewer recurrent thromboembolic events
Less major bleeding events
 Non-superior to Fondaparinux.
 Monitoring: none required in most patients.
Initial Anticoagulation in PE
SC Fondaparinux:
 Recommended for most hemodynamically stable patients.
 Based on multiple studies against IV UFH:
 Same effects on mortality, recurrent thromboembolism, major bleeding.
 Advantages over IV UFH:
 Once or twice daily administration
 Fixed dose
 Less thrombocytopenia
 No monitoring necessary in most patients
Initial Anticoagulation in PE
IV Unfractionated Heparin (IV UFH):
 No longer preferred agent for stable acute PE.
 Preferred Indications:
 Persistent hypotension
 Increased risk of bleeding
 Thrombolysis being considered
 Concern about subcutaneous absorption
 Renal failure
 Obese patients
 Monitoring:
 aPTT
Role of Thrombolytics in PE
Agents:
 tPA:
 Naturally occurring enzyme
 Binds fibrin to enhance plasminogen activation
 Streptokinase:
 Polypeptide derived from beta-hemolytic strep
 Binds to plasminogen to activate plasmin
 Urokinase:
 Occurs naturally in urine
 Plasminogen activator
Role of Thrombolytics in PE
 Indications:
 Persistent hypotension <90 mmHg SBP or decrease in SBP >/=
40mmHg from baseline.
 Potential Indications:
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Severe hypoxemia
Large V/Q mismatch
Extensive clot burden
RV dysfunction
Free-floating atrial/ventricular thrombus
PFO
Cardiopulmonary Resuscitation
Role of Thrombolytics in PE
Role of Thrombolytics in PE
 Purpose : Compare echo parameters and clinical outcome of heparin
vs thrombolysis in first 180 days after SPE w/ RVD.
 Methods: 72 consecutive patients w/ first episode SPE and
symptoms <6 hours w/ CT proven PE and echo proven RVD.
 Results: Thrombolysis group showed significant early improvement in
RV function and this improvement was still observed through the 180
day follow up. Also noted to significant reduction in clinical events
during hospitalization.
Role of Thrombolytics in PE
Role of Thrombolytics in PE
Role of Thrombolytics in PE
 Contraindications:
 Intracranial neoplasm
 Intracranial surgery/trauma (< 2 months)
 Active or recent internal bleeding (< 6 months)
 Hx Hemorrhagic CVA
 Non-hemorrhagic stroke (< 2 months)
 Bleeding diathesis
 Uncontrolled HTN (>200 sbp/110 dbp)
 Surgery (< 10 DAYS)
 Thrombocytopenia ( < 100, 000)
Embolectomy in PE
Embolectomy in PE
Embolectomy:
 Should be considered when patient presentation warrants
thrombolysis but therapy either fails or is contraindicated.
 Can be done surgically or via catheter:
 Dependent upon availabilities and expertise at each individual institution.
Embolectomy in PE
 Surgical Embolectomy:
 Requires cardiopulmonary bypass.
 Has been prompted by:
 failure of initial thrombolysis
 echo evidence of thrombus in:
 R atrium
 R ventricle
 PFO
 Cardiac arrest pre-surgery can be predictive of mortality during
surgery by one small study of 55 pts:
 97% survival of those w/o
 75% survival of those w/
Embolectomy in PE
 Catheter Embolectomy:
 Rheolytic (ie. AngioJet):
 Injection of pressurized saline to macerate emboli. Fragments collected via
exhaust lumen.
 Requires venous cut down.
 Rotational:
 Cardiac catheter equipped with a rotating device that continuously
fragments/aspirates pieces of the thrombus.
 Does not require venous cut down.
 Suction:
 Uses a large lumen catheter to apply direct negative pressure suction w/ an
aspiration syringe.
 Fragmentation:
 Thrombus disruption via manually rotating a standard pigtail catheter or
balloon angio catheter against the thrombus.
Embolectomy in PE
Advanced Interventions: Catheter
Directed Intervention
Advanced Interventions:
Catheter Directed Intervention
Indications for catheter based intervention in the setting of acute
massive PE should include one of the following
 Arterial hypotension. defined as systolic arterial pressure ≤ 90 mm
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Hg, a drop in systolic arterial pressure ≥ 40 mm Hg for ≥ 15
minutes, or ongoing administration of catecholamine for the
treatment of systemic arterial hypotension;
Cardiogenic shock with peripheral hypoperfusion and hypoxia;
Circulatory collapse, including syncope or need for
cardiopulmonary resuscitation;
Echocardiographic findings indicating right ventricular dilatation
and/or pulmonary hypertension;
Subtotal or total filling defect in the left and/or right main
pulmonary artery determined by chest computed tomography
(CT) scan or by conventional pulmonary angiography; or
Widened arterial-alveolar O2 gradient (> 50 mm Hg).
Advanced Interventions:
Catheter Directed Intervention
Advanced Interventions:
Catheter Directed Intervention
 Meta-analysis examining 594 patients from 35
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studies
Patients with acute massive PE treated with
modern CDT
Clinical success defined as stabilization of
hemodynamics, resolution of hypoxia, and
survival
Pooled clinical success rate of CDI was 86.5%
Risk of minor and major complications were
7.9% and 2.4% respectively
Advanced Interventions-EKOS
Ultrasound accelerated catheter directed thrombolysis
 Delivered via an infusion catheter that emits ultrasound energy
to accelerate the thrombolytic cascade
 This is achieved by using the EkoSonic Endovascular System
that is manufactured by the EKOS corporation
 Acoustic energy leads to breakdown of fibrin and increases
fibrin porosity without causing distal embolization
 This facilitates penetration of thrombolytic drugs
Advanced Interventions-EKOS
Advanced Interventions-EKOS
 Patients were randomized into EKOS group and conventional
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CDI group who received either tPA or urokinase
Complete thrombolysis: More than 90% thrombus removal
Near complete lysis: 75-90% removal of thrombus
Partial lysis: 50-75% removal
Follow-up pulmonary angiography performed 12-48 hours
after initiation of intervention to determine progression of
thrombus disruption
Advanced Interventions-EKOS
Advanced Interventions-EKOS
Advanced Interventions-EKOS
 59 patients with acute main or lower lobe PE and RV/LV
ratio of >1
 Randomized to receive either ultrasound assisted catheter
directed thrombolysis vs. unfractionated heparin alone
 Primary outcome was the difference in RV/LV ratio from
baseline to 24 hours
 Safety outcomes included death, major or minor bleeding,
and recurrent VTE at 90 days
Advanced Interventions-EKOS
Advanced Interventions-EKOS
 Significant reduction in RV/LV ratio in study group
 Significant reduction in pulmonary artery and right atrial
pressures
 Significant increase in cardiac index
 No recurrent VTE or hemodynamic decompensation
 No major bleeding complications. 3 patients (10%)
experienced minor bleeding complications
Advanced Interventions-EKOS
Advanced Interventions-EKOS
Advanced Interventions-EKOS
References

Ogata T,Yasaka M, Wakugawa Y, Inoue T, Ibayashi S, Okada Y. Deep venous thrombosis after acute intracerebral
hemorrhage. J Neurol Sci. 2008;272(1-2):83
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Christensen MC, Dawson J, Vincent C. Risk of thromboembolic complications after intracerebral hemorrhage
according to ethnicity. Adv Ther. 2008;25(9):831.
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Skaf E, Stein PD, Beemath A, Sanchez J, Bustamante MA, Olson RE. Venous thromboembolism in patients with
ischemic and hemorrhagic stroke. Am J Cardiol. 2005;96(12):1731.
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Orken DN, Kenangil G, Ozkurt H, Guner C, Gundogdu L, Basak M, Forta H. Prevention of deep venous
thrombosis and pulmonary embolism in patients with acute intracerebral hemorrhage. Neurologist.
2009;15(6):329.
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CLOTS (Clots in Legs Or sTockings after Stroke) Trials Collaboration, Dennis M, Sandercock P, Reid J, Graham
C, Forbes J, Murray G. Effectiveness of intermittent pneumatic compression in reduction of risk of deep vein
thrombosis in patients who have had a stroke (CLOTS 3): a multicentre randomised controlled trial. Lancet.
2013;382(9891):516.
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Paciaroni M, Agnelli G, Venti M, Alberti A, Acciarresi M, Caso V. Efficacy and safety of anticoagulants in the
prevention of venous thromboembolism in patients with acute cerebral hemorrhage: a meta-analysis of controlled
studies. J Thromb Haemost. 2011;9(5):893