In a patient with massive thromboembolism with hypotension after a fluid bolus of 1 L, the patient’s blood pressure remains low at 88/50 mmHg.Echocardiogram demonstrates hypokinesis of the right ventricle.What is the next best step in management of this patient?
This patient is presenting with massive pulmonary embolus with ongoing hypotension, right ventricular dysfunction, and profound hypoxemia requiring 100% oxygen.
In this setting, continuing with anticoagulation alone is inadequate, and the patient should receive circulatory support with fibrinolysis, if there are no contraindications to therapy.
The major contraindications to fibrinolysis include hypertension >180/110 mmHg, known intracranial disease or prior hemorrhagic stroke, recent surgery, or trauma.
The recommended fibrinolytic regimen is recombinant tissue plasminogen activator (rTPA), 100 mg IV over 2 h.
Heparin should be continued with the fibrinolytic to prevent a rebound hypercoagulable state with dissolution of the clot.
There is a 10% risk of major bleeding with fibrinolytic therapy with a 1–3% risk of intracranial hemorrhage. The only indication for fibrinolysis in pulmonary embolus (PE) is for massive PE presenting with life-threatening hypotension, right ventricular dysfunction, and refractory hypoxemia.
In submassive PE presenting with preserved blood pressure and evidence of right ventricular dysfunction on echocardiogram, the decision to pursue fibrinolysis is made on a case-by-case situation. In addition to fibrinolysis, the patient should also receive circulatory support with vasopressors.
Dopamine and dobutamine are the vasopressors of choice for the treatment of shock in PE. Caution should be taken with ongoing high-volume fluid administration as a poorly functioning right ventricle may be poorly tolerant of additional fluids.
Ongoing fluids may worsen right ventricular ischemia and further dilate the right ventricle, displacing the interventricular septum to the left to worsen cardiac output and hypotension. If the patient had contraindications to fibrinolysis and was unable to be stabilized with vasopressor support, referral for surgical embolectomy should be considered.
Referral for inferior vena cava filter placement is not indicated at this time. The patient should be stabilized hemodynamically as a first priority.
The indications for inferior vena cava filter placement are active bleeding, precluding anticoagulation, and recurrent deep venous thrombosis on adequate anticoagulation.
Treat with dopamine and recombinant tissue plasminogen activator, 100 mg IV
Continue IV fluids at 500 mL/hr for a total of 4 L of fluid resuscitation.
Refer for inferior vena cava filter placement and continue current management.
Refer for surgical embolectomy.