Masif Pulmoner Tromboembolide Yoğun Bakım Yönetimi
Özet
50 yaşında, bilinen ailesel hiperlipidemi tanılı kadın olgu 1 aydır olan göğüs ağrısı ile kardiyoloji servisine yatırıldı. Koroner anjiografi yapılarak cerrahi kararı verilen olgu kalp damar cerrahisine nakledilerek koroner arter bypass cerrahisi uygulandı. Postoperatif 7. günde ani solunum sıkıntısı gelişen olgunun çekilen Toraks Anjio Bilgisayarlı Tomografi’sinde; pulmoner bifurkasyonda, her iki ana pulmoner arterde, lomber ve segmental dallarında emboliyle uyumlu dolum defektleri saptandı. Yatak başı EKO’da SPAP 45 mmHg. Taşikardik ve hipoksemik olan ve izleminde hemodinamisi de unstabil olan olgu genel yoğun bakım ünitesine transfer edildi. Oksijen tedavisi altında ciddi hipoksemik (PaO2=41.6 mmHg) olan olgu, NIV desteğine alındı. Kan analizlerinin kontrolü ile doku plazminojen aktivatörü alteplaz ile trombolitik tedavi uygulandı. Ardından heparin infizyonu ile aktive parsiyel tromboplastin zamanı (aptt) takibi yapılarak 2 gün NIV desteğinde izlendi. Tedavinin 4. günü oksijen desteğinde servise alınıp, 7. gününde INR takibi yapılarak varfarin tedavisi başlandı. Olgu 10. gününde, oksijensiz olarak idame tedavisi düzenlenerek şifa ile taburcu edildi.
A 50 years old woman with a known familial hyperlipidemia diagnosis was admitted to the cardiology ward with chest pain lasting for 1 month. After coronary angiography, the patient was transferred to the cardiovascular surgery department and coronary artery bypass surgery was performed. On the 7th postoperative day, the patient developed sudden respiratory distress and in the Thoracic Angiography Computerized Tomography, filling defects compatible with embolism were detected in the pulmonary bifurcation, both main pulmonary arteries, and lumbar and segmental branches. Bedside echocardiography showed SPAP 45 mmHg. The patient, who was tachycardic and hypoxemic and whose hemodynamics were unstable during follow-up, was transferred to the general intensive care unit. The patient, who was severely hypoxemic (PaO2=41.6 mmHg) under oxygen therapy, was placed on NIV support. Thrombolytic treatment was applied with tissue plasminogen activator alteplase under the control of blood analyses. Then, activated partial thromboplastin time (apTT) was monitored with heparin infusion and NIV support was used for 2 days. On the 4th day of treatment, she was admitted to the ward with oxygen support. On the 7th day of treatment, warfarin treatment was started with INR monitoring. The patient was discharged on the 10th day with recovery, with maintenance treatment without oxygen.
Referanslar
Mayo JR, Remy-Jardin MR, Müller NL, et al. Pulmonary embolism: prospective comparison of spiral CT with ventilation perfusion scintigraphy. Radiology 1997;205:447-52.
Trowbridge RL, Araoz PA, Gotway MB, et al. The effect of helical computed tomography on dianostic and treatment strategies in patient with suspected pulmonary embolism. Am J Med 2004; 116:84-90.
Shopp JD, Stewart LK, Emmett TW, et al. Findings from 12- lead electrocardiography that predict circulatory shock from pulmonary embolism: systematic review and meta-analysis. Acad Emerg Med 2015;22:1127.
Goodacre S, Sampson F, Thomas S, et al. Systematic review and meta-analysis of the diagnostic accuracy of ultrasonography for deep vein thrombosis. BMC Med Imaging 2005;5:6.
Stein PD, Hull RD, Patel KC, et al. D-dimer for the exclusion of acute venous thrombosis and pulmonary embolism: a systematic review. Ann Intern Med 2004;140:589-602.
Uresandi F, Blanquer J, Conget F, et al. Guidelines for the diagnosis, treatment, and follow-up of pulmonary embolism. Arch Bronconeumol 2004;40:580-94.
Righini M, Goehring C, Bounameaux H, et al. Effects of age on the performance of common diagnostic tests for pulmonary embolism. Am J Med 2000;109:357361.
Vanni S, Viviani G, Baioni M, et al. Prognostic value of plasma lactate levels among patients with acute pulmonary embolism: the thromboembolism lactate outcome study. Ann Emerg Med 2013;61:330-8.
Vanni S, Nazerian P, Bova C, et al. Comparison of clinical scores for identification of patients with pulmonary embolism at intermediate-high risk of adverse clinical outcome: the prognostic role of plasma lactate. Intern Emerg Med 2017;12:657-65.
Messika J, Goutorbe P, Hajage D, et al. Severe pulmonary embolism managed with high-flow nasal cannula oxygen therapy. Eur J Emerg Med 2017;24:230-2.
Konstantinides S, Meyer G, Becattini C, et al. 2019 ESC guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS). Eur Heart J 2019;1-61.
Kurnicka K, Lichodziejewska B, Goliszek S, et al. Echocardiographic pattern of acute pulmonary embolism: analysis of 511 consecutive patients. J Am Soc Echocardiogr 2016;29:907-13.
Banerjee TP, Mora JC. The management of pulmonary embolism. Anaesthesia and Intensive Care Medicine. https://doi. org/10.1016/j.mpaic.2019.12.008.
Meyer G, Vicaut E, Danays T, et al. Fibrinolysis for patients with intermediate-risk pulmonary embolism. N Engl J Med 2014;370:1402-11.
Konstantinides SV, Torbicki A, Agnelli G et al. ESC guidelines on the diagnosis and management of acute pulmonary embolism. Eur Heart J. 2014;35(43):3033-69.
Kearon C, Kahn SR, Agnelli K, et al. Antithrombotic therapy for venous thromboembolic disease. ACCP evidence based clinical practice guidelines (8th ed). Chest 2008;133:454-545.
Dalla-Volta S, Palla A, Santolicandro A, et al. PAIMS 2: alteplase combined with heparin versus heparin in the treatment of acute pulmonary embolism. Plasminogen activator Italian multicenter study 2. J Am Coll Cardiol 1992;20:520-6.
Kearon C, Akl EA, Comerota AJ, et al. Antithrombotic therapy for VTE disease: antithrombotic therapy and prevention of thrombosis, 9th ed.: American College of Chest Physicians evidence-based clinical practice guidelines. Chest 2012;141(2 Suppl):419-94.
Raschke RA, Reilly BM, Guidry JR, et al. The weight-based heparin dosing nomogram compared with a standard care nomogram: A randomised controlled trial. Ann Intern Med 1993;119:874-81.
Brill-Edwards P, Ginsberg JS, Jhonston M, et al. Establishing a therapeutic range for heparin therapy. Ann Intern Med 1993;119:104-9.
Hull RD, Raskob GE, Hirsh J, et al. Continuous intravenous heparin compared with intermittent subcutaneous heparin in the initial treatment of proximal-vein thrombosis. N Engl J Med 1986;315:1109-14.
Antithrombotic therapy and prevention of thrombosis, 9th ed: ACCP Guidelines Chest 2012;141(Suppl):152S-84S.
Kayaalp SO. Antitrombotik ilaçlar. In: Kayaalp SO ed. Rasyonel tedavi yönünden tıbbi farmakoloji. Dokuzuncu baskı. Ankara, Hacettepe Taş Kitapçılık Ltd Şti., 2000: 584-617.
Van der Hulle T , Huisman MV , Klok FA . Meta-analysis of the efficacy and safety of new oral anticoagulants in patients with cancer-associated acute venous thromboembolism: reply . J Thromb Haemost 2014 ; 12 : 2138 – 9 .
