#Pulmonary_Embolism_9 #PE PE treatment part 3 Source : Tips | "لعلي أفيدك" Clinical discussion

#Pulmonary_Embolism_9 #PE
PE treatment part 3
Source : Tips & Tricks in Cardiology & #BMJ & #ESC

بدأنا بال management لل Hemodynamic unstable
( High Risk pt)
وشفنا متى هنحتاج Respiratory support ومتى المريض هيحتاج fluid resuscitation ومتى هنلجأ لل Noradrenaline او ال dobutamine
وكان ال 1st line هو ال Reperfusion باستخدام ال Systemic thrombolysis ولو كانت C.I في بديلين :
Surgical pulmonary embolectomy
Or
Percutaneous catheter-directed treatment

وطبعا المريض هياخد anticoagulant وهنستخدم UFH ..

Some Notes From #BMJ :

Do not allow supportive therapy to delay thrombolysis (as long as there are no contraindications) it may quickly restore haemodynamic stability.

It is common practice to give thrombolysis as first-line treatment for any patient who is in peri-arrest/cardiac arrest based on clinical suspicion of PE without waiting for results from investigations.

In these situations the decision to give thrombolysis would be based on discussion between senior clinicians

In practice, almost any contraindication to thrombolysis should be considered only relative in high-risk patients who present with haemodynamic instability ,This is because the mortality risk from high-risk PE is so high that it is likely to outweigh any bleeding risk from thrombolysis in this patient group


بعد ما المريض ياخد ال Thrombolysis ويستقر ..
هنكمل على ال UFH

Following thrombolysis, patients should be fully anticoagulated with IV UFH.

However, to minimize the risk of bleeding, you should check an activated partial thromboplastin time (aPTT) and resume UFH without a loading dose when the aPTT is less than twice its upper limit of normal.

If the aPTT exceeds this value, it should be repeated every four hours until it is less than twice its upper limit of normal, at which time, resume a heparin infusion.

In the UK it is common practice to stop UFH within 24 hours.

مش هنبدأ للمريض NOACs او LMWH إلا بعد مرور 24 ساعه على الاقل من ال Thrombolysis administration

Once stable for 24 to 48 hours, patients should be transitioned to an oral agent (eg, DOAC or warfarin).

If switching to rivaroxaban or apixaban, these drugs may be started after stopping UFH without the need for lead-in therapy with a parenteral anticoagulant.

Acute-phase treatment consists of an increased dose of the oral anticoagulant over the first 3 weeks (for rivaroxaban), or over the first 7 days (for apixaban).

If switching to LMWH, the total duration of treatment with UFH and then LMWH should be at least 5 days.

If ongoing anticoagulation will be with edoxaban or dabigatran, at least 5 days of lead-in therapy with a parenteral anticoagulant is required first.
Stop the parenteral anticoagulant before starting dabigatran or edoxaban

If ongoing anticoagulation will be with warfarin, ensure overlap with a parenteral anticoagulant for at least 5 days or until the INR is ≥2 for at least 24 hours (whichever is the longer).


Doses :
apixaban : 10 mg orally twice daily for 7 days, followed by 5 mg twice daily

rivaroxaban : 15 mg orally twice daily for 21 days, followed by 20 mg once daily

edoxaban : start following initial use of a parenteral anticoagulant for at least 5 days; body weight ≤60 kg: 30 mg orally once daily; body weight >60 kg: 60 mg orally once daily

dabigatran : start following initial use of a parenteral anticoagulant for at least 5 days;
18-74 years of age: 150 mg orally twice daily;
75-79 years of age: 110-150 mg orally twice daily;
≥80 years of age: 110 mg orally twice daily

Enoxaparin : 1 mg/kg every 12 hours (preferred) or 1.5 mg/kg once every 24 hours.
Or
body weight <50 kg: 40 mg subcutaneously twice daily;
body weight 50-69 kg: 60 mg subcutaneously twice daily;
body weight 70-89 kg: 80 mg subcutaneously twice daily;
body weight ≥90 kg: 100 mg subcutaneously twice daily

#لعلي_أفيدك
البوست القادم ان شاء الله هنكمل مع ال Moderate- Low risk PE