Recent advances in the management of pulmonary embolism: focus on the critically ill patients.
Recent advances in the management of pulmonary embolism: focus on the critically ill patients.
复制标题
DOI：
10.1186/s13613-016-0122-z
复制
发表时间：
2016-12
影响因子：
8.1
通讯作者：
Planquette B
中科院分区：
文献类型：
--
作者：
Meyer G;Vieillard-Baron A;Planquette B
这篇叙述性综述的目的是为重症监护医师或任何管理“严重”肺栓塞（PE）的医生总结患者护理方面的主要最新进展或建议，包括风险分层、诊断算法、重症监护病房（ICU）的血流动力学管理、有关溶栓治疗和可回收腔静脉过滤器使用的最新数据以及直接口服抗凝剂的最终结果。由于PE患者风险分层的改进，从诊断算法和适应症到ICU入院，再到休克患者的溶栓指征和一般血流动力学支持，现在推荐了更好的治疗方法。在目前的剂量下，溶栓治疗与中危PE患者死亡率和血流动力学失代偿的联合终点降低有关，但这并没有降低总死亡率，而是显著增加了主要的颅外和颅内出血。对于高、中危PE患者，如果血流动力学恶化，应给予溶栓治疗。当抗凝治疗无禁忌症时，腔静脉滤过器几乎没有帮助，即使是有PE和临床严重程度的患者。最后，在静脉血栓栓塞和中低风险PE患者中，直接口服抗凝剂已被证明与联合使用低分子肝素和维生素K拮抗剂一样有效且更安全。
The aim of this narrative review is to summarize for intensivists or any physicians managing “severe” pulmonary embolism (PE) the main recent advances or recommendations in the care of patients including risk stratification, diagnostic algorithm, hemodynamic management in the intensive care unit (ICU), recent data regarding the use of thrombolytic treatment and retrievable vena cava filters and finally results of direct oral anticoagulants. Thanks to the improvements achieved in the risk stratification of patients with PE, a better therapeutic approach is now recommended from diagnosis algorithm and indication to admission in ICU to indication of thrombolysis and general hemodynamic support in patients with shock. Given at current dosage, thrombolytic therapy is associated with a reduction in the combined end-point of mortality and hemodynamic decompensation in patients with intermediate-risk PE, but this is obtained without a decrease in overall mortality and with a significant increase in major extracranial and intracranial bleeding. In patients with high-intermediate-risk PE, thrombolytic therapy should be given in case of hemodynamic worsening. Vena cava filters are of little help when anticoagulant treatment is not contraindicated, even in patients with PE and features of clinical severity. Finally, direct oral anticoagulants have been shown to be as effective as and safer than the combination of low molecular weight heparin and vitamin K antagonist(s) in patients with venous thromboembolism and low- to intermediate-risk PE.