Case report
Successful systemic thrombolysis in a patient with massive pulmonary thromboembolism after prolonged cardio pulmonary and cerebral resuscitation. Case report
Trombolisis sistémica exitosa en un paciente con tromboembolismo pulmonar masivo, luego de reanimación cardiocerebropulmonar prolongada. Informe de caso
Gustavo Chicanganaa,
, Lorena Zapatab, Juan Camilo Gómezc, Juan Pablo Zuluagad
Corresponding author
gustavochicangana@gmail.com
Corresponding author at: Carrera 25 No. 52-30, Edificio Versalles Plaza, Manizales, Colombia.
Corresponding author at: Carrera 25 No. 52-30, Edificio Versalles Plaza, Manizales, Colombia.
a MD Surgeon, 3rd Year Resident of Anesthesiology, Universidad de Caldas, Manizales, Colombia
b MD Surgeon, SES Hospital de Caldas, Manizales, Colombia
c Anesthesiologist, Director of the Graduate Program of Anesthesiology, Universidad de Caldas, Manizales, Colombia
d Intensivist, SES Hospital de Caldas, Manizales, Colombia
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Informe de caso" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "fuente" => "<span class="elsevierStyleItalic">Source</span>: Authors." "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1040 "Ancho" => 1250 "Tamanyo" => 121409 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Moderate right ventricular dilatation. VD: right ventricle, VI: left ventricle.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Pulmonary thromboembolism (PTE) is defined as a partial or complete obstruction of the pulmonary artery or any of its branches potentially resulting in acute right ventricular insufficiency and cardiogenic shock. Around 90–95% of the emboli originate from the venous system of the lower extremities.<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">1–3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The estimated incidence of PTE is 70–200 cases per 100,000 inhabitants per year,<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">2,4,5</span></a> and it has a strong direct correlation with age.<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">6,7</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">In many cases PTE is asymptomatic or has a non-specific clinical evolution and is only identified in about 60% of the cases.<a class="elsevierStyleCrossRefs" href="#bib0145"><span class="elsevierStyleSup">8,9</span></a> Some studies suggest that up to 60% of all hospitalized patients may have PTE, representing the primary cause of preventable deaths in this type of patients.<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">1</span></a> PTE is the third cause of cardiovascular death, following myocardial infarction and cerebrovascular disease.<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">10</span></a> The overall hospital mortality due to PTE in Colombia is approximately 14.8%. Proper management may reduce this rate from 15–30% down to 3–10%.<a class="elsevierStyleCrossRefs" href="#bib0160"><span class="elsevierStyleSup">11,12</span></a> 30% of the patients that survive an acute episode of PTE will experience residual symptoms and 2% develop pulmonary hypertension.<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">13</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">The clinical guidelines suggest classifying the patient into four categories for the diagnostic and therapeutic approach<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">13,14</span></a>:</p><p id="par0025" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">High risk:</span> patients with PTE severity index (PESI) Class III–V (massive PTE), severe right ventricle (RV) dysfunction, elevated cardiac biomarkers, hypotension, cardiogenic shock or respiratory arrest.</p><p id="par0030" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Intermediate high risk:</span> patients with PESI Class III–V, RV dysfunction, elevated cardiac biomarkers with no hypotension or shock.</p><p id="par0035" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Intermediate low risk:</span> patients with PESI Class III–V, RV dysfunction or elevated cardiac biomarkers or none of the above.</p><p id="par0040" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Low risk:</span> patients with PESI Class I–II, minor symptoms such as chest pain and tachycardia produced by small clots in the distal pulmonary circulation, with no signs of RV dysfunction or elevation of cardiac biomarkers.<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">13,14</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">The therapeutic options for PTE management include systemic anticoagulation, systemic thrombolysis, catheter-directed thrombolysis (CDT) and surgical thrombectomy.<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">15</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">Systemic thrombolysis reduces the mortality in high-risk patients<a class="elsevierStyleCrossRefs" href="#bib0185"><span class="elsevierStyleSup">16,17</span></a> and may be considered for intermediate-high risk patients<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">14</span></a>; its principal benefit is based on the quick recovery of the pulmonary blood flow, but it is associated with major bleeding complications in up to 20% of the cases, and with intracranial hemorrhage with an incidence of 0.9–5%.<a class="elsevierStyleCrossRefs" href="#bib0185"><span class="elsevierStyleSup">16,18</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">In high-risk PTE patients and with absolute or relative contraindications for systemic thrombolysis,<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">14</span></a> the guidelines specify that systemic thrombolysis could be considered in the presence of immediate life-threatening risk. Furthermore, alternative therapies have been proposed in the literature, including CDT and surgical thrombectomy that should be performed at specialized institutions.<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">15</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">Upon approval by the institution's ethics committee and by the patient, a clinical case of a young man admitted to the emergency department with high-risk PTE is discussed. The patient presented with cardiorespiratory arrest on 5 occasions, requiring prolonged CPCR and finally undergoes systemic thrombolysis with satisfactory results and with no pulmonary or neurological sequelae. The article is proprietary of the authors.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Clinical case description</span><p id="par0065" class="elsevierStylePara elsevierViewall">29-year old man, mestizo, biologist, with no relevant personal or family history, healthy life-style, who 15 days prior to admission developed a lesion in the right knee meniscus while practicing sports but did not require surgical management. While receiving physical therapy the patient presented three seizure episodes followed by syncope. The patient was admitted fully conscious to the emergency department complaining of chest pain and dyspnea. During the first hour the patient developed 5 episodes of cardiac arrest, one of them lasted for 20<span class="elsevierStyleHsp" style=""></span>min, documenting pulseless electrical activity (PEA). CPCR maneuvers were implemented and spontaneous circulation in sinus tachycardia was restored.</p><p id="par0070" class="elsevierStylePara elsevierViewall">There were no economic, cultural or linguistic barriers for the diagnostic approach. A transthoracic ECG evidenced a moderately dilated right ventricle with free wall hypokinesis (TAPSE 9.2<span class="elsevierStyleHsp" style=""></span>mm), a systolic pulmonary pressure of 55<span class="elsevierStyleHsp" style=""></span>mmHg, moderately dilated pulmonary artery and hyper-dynamic left ventricle (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0075" class="elsevierStylePara elsevierViewall">The patient was transferred to Intensive Care with invasive ventilation support and noradrenalin infusion at 0.1<span class="elsevierStyleHsp" style=""></span>mcg/k/min and vasopressin at 0.01<span class="elsevierStyleHsp" style=""></span>μ/min. A chest CT angiography was positive for massive pulmonary thromboembolism involving both lower lobes and the left upper lobe associated with signs of severe pulmonary hypertension (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>).</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0080" class="elsevierStylePara elsevierViewall">Within the clinical context of a patient with high-risk PTE, prolonged CPCR, and elevated risk for hemorrhagic complications with the administration of systemic thrombolysis, a CDT is initially suggested. However, the Cat-Lab was not available at that time and the patient's conditions were not adequate for transfer. A doctor's meeting was convened and considering the impending life-threatening high risk for the patient, the decision was to administer systemic thrombolysis. Upon obtaining the patient's informed consent, thrombolysis therapy with 100<span class="elsevierStyleHsp" style=""></span>mg of tissue plasminogen activator (Alteplase) was initiated, which was well tolerated, with no evidence of major bleeding. Cerebral hemorrhage was ruled out with neuroimaging and protective hypothermia was initiated. There was a remarkable hemodynamic improvement in the following 12<span class="elsevierStyleHsp" style=""></span>h and vasopressor requirements decreased.</p><p id="par0085" class="elsevierStylePara elsevierViewall">A Doppler study confirmed the presence of deep vein thrombosis of the popliteal and posterior tibial veins, in addition to the soleal venous plexus of the right lower extremity. Ventilation support and vasopressors were removed after 48<span class="elsevierStyleHsp" style=""></span>h. The patient was discharged 10 days later with no neurological sequelae and no supplemental oxygen, with oral anticoagulation and was referred for blood tests to rule out thrombophilia. <a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a> illustrates a summary of the patient's key events.</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0090" class="elsevierStylePara elsevierViewall">In patients with high risk PTE and an extremely critical condition to perform chest CT angiography, the ECG at the patient's bedside may help in identifying any signs suggestive of PTE.<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">19</span></a> If PTE is a known or suspected cause of cardiac arrest, thrombolysis may help to recover spontaneous circulation and ensure high survival rates.<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">20</span></a> However, in the particular case under discussion, an ultrasound machine was not available to quickly guide the diagnosis; since the administration of thrombolytic agents to patients in cardiac arrest of undifferentiated causes is not associated with a significant benefit in terms of mortality,<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">21</span></a> the decision adopted was to stabilize the patient's hemodynamic condition while confirmatory tests could be performed.</p><p id="par0095" class="elsevierStylePara elsevierViewall">Notwithstanding the relative contraindication of prolonged CPCR for the administration of systemic thrombolysis, once PTE is diagnosed in a patient at life-threatening risk, and in the absence of a CatLab for CDT, the decision was to administer Alteplase, with remarkable clinical improvement and no sequelae at discharge.</p><p id="par0100" class="elsevierStylePara elsevierViewall">In conclusion, systemic thrombolytic agents are not considered a contraindication under a life-threatening PTE situation. ECG at the patient's bedside may help to guide the diagnosis and provide quick management response in these cases.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Funding</span><p id="par0105" class="elsevierStylePara elsevierViewall">The authors did not receive sponsorship to undertake this article.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Conflicts of interest</span><p id="par0110" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:3 [ "identificador" => "xres679490" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec685441" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres679489" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec685440" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Clinical case description" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Discussion" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Funding" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Conflicts of interest" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2015-04-17" "fechaAceptado" => "2016-02-02" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec685441" "palabras" => array:5 [ 0 => "Pulmonary embolism" 1 => "Fibrinolytic agents" 2 => "Fibrinolysis" 3 => "Heart arrest" 4 => "Thrombolytic therapy" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec685440" "palabras" => array:5 [ 0 => "Embolismo pulmonar" 1 => "Fibrinolíticos" 2 => "Fibrinólisis" 3 => "Paro cardíaco" 4 => "Terapia trombolítica" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Massive pulmonary thromboembolism is a condition with high morbidity and mortality if not treated early. A case of a young man with a history of knee trauma that was admitted to the emergency department with sudden dyspnea and syncope is discussed. During the clinical evaluation the patient experienced 5 episodes of cardiac arrest that required prolonged cardiopulmonary-cerebral resuscitation. The diagnosis of massive pulmonary thromboembolism was confirmed by echocardiography and thoracic CT angiography. Although prolonged cardiopulmonary-cerebral resuscitation is a relative contraindication for systemic thrombolysis, the patient experienced remarkable clinical improvement with no sequelae upon hospital discharge.</p></span>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">El tromboembolismo pulmonar masivo es una entidad con alta morbilidad y mortalidad si no se trata tempranamente. Se expone el caso de un hombre joven con antecedente de trauma en rodilla quien ingresa al servicio de urgencias por cuadro súbito de disnea y síncope; durante la evaluación clínica presenta 5 episodios de paro cardiaco con requerimiento de reanimación cardiocerebropulmonar prolongada; se confirma el diagnóstico de tromboembolismo pulmonar masivo mediante ecocardiografía y angiotac de tórax. A pesar que la reanimación cardiocerebropulmonar prolongada se considera una contraindicación relativa para trombolisis sistémica, ésta fue administrada, con notoria mejoría clínica, sin ninguna secuela al alta hospitalaria.</p></span>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Chicangana G, Zapata L, Gómez JC, Zuluaga JP. Trombolisis sistémica exitosa en un paciente con tromboembolismo pulmonar masivo, luego de reanimación cardiocerebropulmonar prolongada. Informe de caso. Rev Colomb Anestesiol. 2016;44:245–248.</p>" ] ] "multimedia" => array:3 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "fuente" => "<span class="elsevierStyleItalic">Source</span>: Authors." "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1040 "Ancho" => 1250 "Tamanyo" => 121409 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Moderate right ventricular dilatation. VD: right ventricle, VI: left ventricle.</p>" ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "fuente" => "<span class="elsevierStyleItalic">Source</span>: Authors." "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 578 "Ancho" => 901 "Tamanyo" => 65128 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Filling defect with involvement of the right and left pulmonary arteries. The left side extends through the arteries into the upper and lower lobes.</p>" ] ] 2 => array:8 [ "identificador" => "fig0015" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "fuente" => "<span class="elsevierStyleItalic">Source</span>: Authors." 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 10 | 2 | 12 |
| 2024 October | 27 | 4 | 31 |
| 2024 September | 49 | 7 | 56 |
| 2024 August | 42 | 4 | 46 |
| 2024 July | 32 | 1 | 33 |
| 2024 June | 31 | 5 | 36 |
| 2024 May | 41 | 4 | 45 |
| 2024 April | 31 | 1 | 32 |
| 2024 March | 29 | 4 | 33 |
| 2024 February | 97 | 9 | 106 |
| 2024 January | 53 | 9 | 62 |
| 2023 December | 44 | 16 | 60 |
| 2023 November | 71 | 11 | 82 |
| 2023 October | 52 | 12 | 64 |
| 2023 September | 45 | 6 | 51 |
| 2023 August | 39 | 7 | 46 |
| 2023 July | 25 | 4 | 29 |
| 2023 June | 47 | 5 | 52 |
| 2023 May | 53 | 6 | 59 |
| 2023 April | 63 | 3 | 66 |
| 2023 March | 87 | 4 | 91 |
| 2023 February | 57 | 15 | 72 |
| 2023 January | 26 | 4 | 30 |
| 2022 December | 48 | 6 | 54 |
| 2022 November | 43 | 6 | 49 |
| 2022 October | 41 | 9 | 50 |
| 2022 September | 34 | 9 | 43 |
| 2022 August | 20 | 5 | 25 |
| 2022 July | 24 | 8 | 32 |
| 2022 June | 33 | 9 | 42 |
| 2022 May | 27 | 16 | 43 |
| 2022 April | 19 | 8 | 27 |
| 2022 March | 27 | 14 | 41 |
| 2022 February | 28 | 4 | 32 |
| 2022 January | 32 | 7 | 39 |
| 2021 December | 35 | 8 | 43 |
| 2021 November | 10 | 6 | 16 |
| 2021 October | 41 | 13 | 54 |
| 2021 September | 34 | 8 | 42 |
| 2021 August | 33 | 4 | 37 |
| 2021 July | 50 | 6 | 56 |
| 2021 June | 14 | 6 | 20 |
| 2021 May | 33 | 8 | 41 |
| 2021 April | 53 | 25 | 78 |
| 2021 March | 28 | 9 | 37 |
| 2021 February | 8 | 5 | 13 |
| 2021 January | 12 | 8 | 20 |
| 2020 December | 11 | 4 | 15 |
| 2020 November | 20 | 6 | 26 |
| 2020 October | 12 | 8 | 20 |
| 2020 September | 18 | 7 | 25 |
| 2020 August | 11 | 9 | 20 |
| 2020 July | 9 | 8 | 17 |
| 2020 June | 8 | 5 | 13 |
| 2020 May | 11 | 8 | 19 |
| 2020 April | 6 | 4 | 10 |
| 2020 March | 14 | 7 | 21 |
| 2020 February | 8 | 5 | 13 |
| 2020 January | 6 | 2 | 8 |
| 2019 December | 10 | 9 | 19 |
| 2019 November | 6 | 2 | 8 |
| 2019 October | 6 | 2 | 8 |
| 2019 September | 7 | 1 | 8 |
| 2019 August | 0 | 1 | 1 |
| 2019 July | 1 | 5 | 6 |
| 2019 June | 1 | 4 | 5 |
| 2019 May | 2 | 9 | 11 |
| 2019 April | 1 | 0 | 1 |
| 2018 September | 1 | 0 | 1 |
| 2018 June | 3 | 6 | 9 |
| 2018 May | 27 | 5 | 32 |
| 2018 April | 31 | 9 | 40 |
| 2018 March | 21 | 11 | 32 |
| 2018 February | 26 | 9 | 35 |
| 2018 January | 24 | 10 | 34 |
| 2017 December | 27 | 8 | 35 |
| 2017 November | 17 | 5 | 22 |
| 2017 October | 22 | 13 | 35 |
| 2017 September | 22 | 13 | 35 |
| 2017 August | 11 | 10 | 21 |
| 2017 July | 20 | 7 | 27 |
| 2017 June | 24 | 12 | 36 |
| 2017 May | 24 | 11 | 35 |
| 2017 April | 38 | 12 | 50 |
| 2017 March | 18 | 8 | 26 |
| 2017 February | 9 | 5 | 14 |
| 2017 January | 13 | 8 | 21 |
| 2016 December | 33 | 13 | 46 |
| 2016 November | 25 | 10 | 35 |
| 2016 October | 40 | 15 | 55 |
| 2016 September | 75 | 14 | 89 |
| 2016 August | 65 | 12 | 77 |
| 2016 July | 31 | 17 | 48 |
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