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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,
Corresponding author
gustavochicangana@gmail.com

Corresponding author at: Carrera 25 No. 52-30, Edificio Versalles Plaza, Manizales, Colombia.
, Lorena Zapatab, Juan Camilo Gómezc, Juan Pablo Zuluagad
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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of the cases&#46;<a class="elsevierStyleCrossRefs" href="#bib0145"><span class="elsevierStyleSup">8&#44;9</span></a> Some studies suggest that up to 60&#37; of all hospitalized patients may have PTE&#44; representing the primary cause of preventable deaths in this type of patients&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">1</span></a> PTE is the third cause of cardiovascular death&#44; following myocardial infarction and cerebrovascular disease&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">10</span></a> The overall hospital mortality due to PTE in Colombia is approximately 14&#46;8&#37;&#46; Proper management may reduce this rate from 15&#8211;30&#37; down to 3&#8211;10&#37;&#46;<a class="elsevierStyleCrossRefs" href="#bib0160"><span class="elsevierStyleSup">11&#44;12</span></a> 30&#37; of the patients that survive an acute episode of PTE will experience residual symptoms and 2&#37; develop pulmonary hypertension&#46;<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&#44;14</span></a>&#58;</p><p id="par0025" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">High risk&#58;</span> patients with PTE severity index &#40;PESI&#41; Class III&#8211;V &#40;massive PTE&#41;&#44; severe right ventricle &#40;RV&#41; dysfunction&#44; elevated cardiac biomarkers&#44; hypotension&#44; cardiogenic shock or respiratory arrest&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Intermediate high risk&#58;</span> patients with PESI Class III&#8211;V&#44; RV dysfunction&#44; elevated cardiac biomarkers with no hypotension or shock&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Intermediate low risk&#58;</span> patients with PESI Class III&#8211;V&#44; RV dysfunction or elevated cardiac biomarkers or none of the above&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Low risk&#58;</span> patients with PESI Class I&#8211;II&#44; minor symptoms such as chest pain and tachycardia produced by small clots in the distal pulmonary circulation&#44; with no signs of RV dysfunction or elevation of cardiac biomarkers&#46;<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">13&#44;14</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">The therapeutic options for PTE management include systemic anticoagulation&#44; systemic thrombolysis&#44; catheter-directed thrombolysis &#40;CDT&#41; and surgical thrombectomy&#46;<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&#44;17</span></a> and may be considered for intermediate-high risk patients<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">14</span></a>&#59; its principal benefit is based on the quick recovery of the pulmonary blood flow&#44; but it is associated with major bleeding complications in up to 20&#37; of the cases&#44; and with intracranial hemorrhage with an incidence of 0&#46;9&#8211;5&#37;&#46;<a class="elsevierStyleCrossRefs" href="#bib0185"><span class="elsevierStyleSup">16&#44;18</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">In high-risk PTE patients and with absolute or relative contraindications for systemic thrombolysis&#44;<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&#46; Furthermore&#44; alternative therapies have been proposed in the literature&#44; including CDT and surgical thrombectomy that should be performed at specialized institutions&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">15</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">Upon approval by the institution&#39;s ethics committee and by the patient&#44; a clinical case of a young man admitted to the emergency department with high-risk PTE is discussed&#46; The patient presented with cardiorespiratory arrest on 5 occasions&#44; requiring prolonged CPCR and finally undergoes systemic thrombolysis with satisfactory results and with no pulmonary or neurological sequelae&#46; The article is proprietary of the authors&#46;</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&#44; mestizo&#44; biologist&#44; with no relevant personal or family history&#44; healthy life-style&#44; who 15 days prior to admission developed a lesion in the right knee meniscus while practicing sports but did not require surgical management&#46; While receiving physical therapy the patient presented three seizure episodes followed by syncope&#46; The patient was admitted fully conscious to the emergency department complaining of chest pain and dyspnea&#46; During the first hour the patient developed 5 episodes of cardiac arrest&#44; one of them lasted for 20<span class="elsevierStyleHsp" style=""></span>min&#44; documenting pulseless electrical activity &#40;PEA&#41;&#46; CPCR maneuvers were implemented and spontaneous circulation in sinus tachycardia was restored&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">There were no economic&#44; cultural or linguistic barriers for the diagnostic approach&#46; A transthoracic ECG evidenced a moderately dilated right ventricle with free wall hypokinesis &#40;TAPSE 9&#46;2<span class="elsevierStyleHsp" style=""></span>mm&#41;&#44; a systolic pulmonary pressure of 55<span class="elsevierStyleHsp" style=""></span>mmHg&#44; moderately dilated pulmonary artery and hyper-dynamic left ventricle &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;</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&#46;1<span class="elsevierStyleHsp" style=""></span>mcg&#47;k&#47;min and vasopressin at 0&#46;01<span class="elsevierStyleHsp" style=""></span>&#956;&#47;min&#46; 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 &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0080" class="elsevierStylePara elsevierViewall">Within the clinical context of a patient with high-risk PTE&#44; prolonged CPCR&#44; and elevated risk for hemorrhagic complications with the administration of systemic thrombolysis&#44; a CDT is initially suggested&#46; However&#44; the Cat-Lab was not available at that time and the patient&#39;s conditions were not adequate for transfer&#46; A doctor&#39;s meeting was convened and considering the impending life-threatening high risk for the patient&#44; the decision was to administer systemic thrombolysis&#46; Upon obtaining the patient&#39;s informed consent&#44; thrombolysis therapy with 100<span class="elsevierStyleHsp" style=""></span>mg of tissue plasminogen activator &#40;Alteplase&#41; was initiated&#44; which was well tolerated&#44; with no evidence of major bleeding&#46; Cerebral hemorrhage was ruled out with neuroimaging and protective hypothermia was initiated&#46; There was a remarkable hemodynamic improvement in the following 12<span class="elsevierStyleHsp" style=""></span>h and vasopressor requirements decreased&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">A Doppler study confirmed the presence of deep vein thrombosis of the popliteal and posterior tibial veins&#44; in addition to the soleal venous plexus of the right lower extremity&#46; Ventilation support and vasopressors were removed after 48<span class="elsevierStyleHsp" style=""></span>h&#46; The patient was discharged 10 days later with no neurological sequelae and no supplemental oxygen&#44; with oral anticoagulation and was referred for blood tests to rule out thrombophilia&#46; <a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a> illustrates a summary of the patient&#39;s key events&#46;</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&#44; the ECG at the patient&#39;s bedside may help in identifying any signs suggestive of PTE&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">19</span></a> If PTE is a known or suspected cause of cardiac arrest&#44; thrombolysis may help to recover spontaneous circulation and ensure high survival rates&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">20</span></a> However&#44; in the particular case under discussion&#44; an ultrasound machine was not available to quickly guide the diagnosis&#59; 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&#44;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">21</span></a> the decision adopted was to stabilize the patient&#39;s hemodynamic condition while confirmatory tests could be performed&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">Notwithstanding the relative contraindication of prolonged CPCR for the administration of systemic thrombolysis&#44; once PTE is diagnosed in a patient at life-threatening risk&#44; and in the absence of a CatLab for CDT&#44; the decision was to administer Alteplase&#44; with remarkable clinical improvement and no sequelae at discharge&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">In conclusion&#44; systemic thrombolytic agents are not considered a contraindication under a life-threatening PTE situation&#46; ECG at the patient&#39;s bedside may help to guide the diagnosis and provide quick management response in these cases&#46;</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&#46;</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&#46;</p></span></span>"
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        "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&#46; Se expone el caso de un hombre joven con antecedente de trauma en rodilla quien ingresa al servicio de urgencias por cuadro s&#250;bito de disnea y s&#237;ncope&#59; durante la evaluaci&#243;n cl&#237;nica presenta 5 episodios de paro cardiaco con requerimiento de reanimaci&#243;n cardiocerebropulmonar prolongada&#59; se confirma el diagn&#243;stico de tromboembolismo pulmonar masivo mediante ecocardiograf&#237;a y angiotac de t&#243;rax&#46; A pesar que la reanimaci&#243;n cardiocerebropulmonar prolongada se considera una contraindicaci&#243;n relativa para trombolisis sist&#233;mica&#44; &#233;sta fue administrada&#44; con notoria mejor&#237;a cl&#237;nica&#44; sin ninguna secuela al alta hospitalaria&#46;</p></span>"
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es en pt

¿Es usted profesional sanitario apto para prescribir o dispensar medicamentos?

Are you a health professional able to prescribe or dispense drugs?

Você é um profissional de saúde habilitado a prescrever ou dispensar medicamentos