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Thrombolysis In PE

Thrombolysis In PE. Case III. 54 y male POD #1 LLL lobectomy ? Ca PMH : HTN , A Fib , DM II , COPD Rx : Digoxin , Lasix , Metformin , ASA enalapril & bronchodilator Post op SOB. History. Sudden onset of diaphoresis & SOB No chest pain , fever , wheeze , cough

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Thrombolysis In PE

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  1. Thrombolysis In PE

  2. Case III • 54 y male POD #1 LLL lobectomy ? Ca • PMH : HTN , A Fib , DM II , COPD • Rx : Digoxin , Lasix , Metformin , ASA enalapril & bronchodilator • Post op SOB

  3. History • Sudden onset of diaphoresis & SOB • No chest pain , fever , wheeze , cough • No abdominal or leg pain • 500 NS & 1000 pentaspan was given BP 75/55 baseline 120/70

  4. Examination • BP 80/55 HR 90 A fib RR 25 Temp 37 Sat 94% on 5 L O2 • Cool mottled skin , conscious +ve accessory muscles • JVP difficult ? 5cm ASA • Epidural in place

  5. Examination • CVS : S1+S2 ? S3 • Chest : Clean wound Good AE No wheeze ,crackles Chest tube no air leak • Abd & LL  NAD

  6. Investigation • WBC 19 Poly 75% Hb 112 Plt & Coagulation N • Creat 115 K 2.9 • ABG PH 7.43 PCO2 39 HCo3 22 PO2 135 on 7 L O2 • CXR & CT

  7. Hospital Course • Transferred to SICU • Intubated  hypoxia & Shock • ARF & Shocked liver • TEE  Dilated RV with RWMA LVEF 35% Pulmonary HTN • CK 5000 TnT 5 Lactate 18

  8. Hospital Course • Received tPA Hb 100 80 No heparin INR 2.5 • CRRT  FIO2 55% • CI 3.2 on 1.5 mcg /kg Levo & .5mcg/kg Millrinone • Recurrent episodes of VT/ SVT  multiple DC shocks

  9. Hospital Course • OR pathology  Hamrtoma • Same condition for 3 days • Family meeting • Withdrawal of support

  10. Thrombolysis In PE • Streptokinase RCT SK 1.5 million IU /1 hour Vs heparin 8 pt All 4 pt rx with heparin died postmortem shows massive PE All 4 with SK had hemodynamic improvement & alive at 2 y follow up J Thromb Thrombolysis. 1995

  11. Thrombolysis In PE • rtPA Chest. 1990 Dec RCT rtPA 40-80 mg over 90-120 mint VS Placebo 13 patient End point hemodynamic effect & clot resolution Initial improvement in rtPA PVR at 60 mint which didn’t last at 90 mint

  12. Thrombolysis In PE • rtPA VS SK. RCT 90 pt 100 mg rtPA over 2hours Vs SK 24 hours Endpoint angiographic resolution at 2 hours & VQ at 2 days No statistical difference in resolution 2 rtPA Vs 1 SK had ICH J Am Coll Cardiol july 92

  13. Thrombolysis In PE • rtPA bolus Vs 2 h infusion RCT 60 Pt rtPA bolus /15 mint maximum 50mg 27 Pt 100 mg over 2 hours Death 8.3 % Bolus Vs 3.7% Infusion P NS Chest. 94 Sep

  14. Thrombolysis In PE • Alteplase Vs SK RCT 66 pt massive PE Mean PAP > 20 Either 2 h Alteplase or 2 h SK 48 h hemodynamics  SK faster reduction in MAP first 24h but at 48 h SK was equal 1 y follow up recurrence & death equal JA Card 1998 Apr

  15. Thrombolysis In PE • Alteplase in submassive PE RCT 256 pt PE with resp or homodynamic instability 118 Alteplase + heparin Vs 138 heparin Inhospital mortality 3.2 Vs 2.2 P NS Clinical deterioration 10.2 Vs 24.6 P < 0.004 No major bleeding Minor bleeding In Alteplase NEJM oct 02

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