Mike Demeo

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Critical Care MM

• Mike Demeo
• Nikhil Kapila
• April 11, 2014

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Morbidity Mortality Conference

• It is for the department faculty and residents to
  peer review case(s) from the inpatient service.
• The primary objective is to improve overall
  patient care focusing on quality of care
  delivered, performance improvement, patient
  safety and risk management.
• This material is confidential and is utilized as
  defined in Connecticut State statute 19a-17b
  Section(4) for evaluating and improving the
  quality of health care rendered

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Morbidity Mortality Conference

• Goals
• To review recent cases and identify areas for
  improvement for (all) clinicians involved
• Patient complications deaths are reviewed with
  the purpose of educating staff, residents and
  medical students.
• To identify system issues, which negatively
  affect patient care
• To modify behavior and judgment and to prevent
  repetition of errors leading to complications.
• To assess all six ACGME competencies and
  Institute of Medicine (IOM) Values in the quality
  of care delivered
• Conferences are non punitive and focus on the
  goal of improved and safer patient care
• This material is confidential and is utilized as
  defined in Connecticut State statute 19a-17b
  Section(4) for evaluating and improving the
  quality of health care rendered

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Morbidity Mortality Conference

• Every Defect is a Treasure
• This material is confidential and is utilized as
  defined in Connecticut State statute 19a-17b
  Section(4) for evaluating and improving the
  quality of health care rendered

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Every Defect is a Treasure

• Errors are due to
• Processes 80
• Individuals 20
• Translate all error into education
• This material is confidential and is utilized as
  defined in Connecticut State statute 19a-17b
  Section(4) for evaluating and improving the
  quality of health care rendered

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Learning Objectives-

• What is the role for DVT prophylaxis in patients
  with recent intracranial hemorrhage?
• What are the roles of thrombolytics and heparin
  in the management of PE?
• What are the other options in treating PE?
• Embolectomy
• EKOS

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VTE in patients with a history of ICH

• DVT has been reported in 2-15 of patients with
  ICH
• PE occurs in 1-5 of patients
• Usually 2-4 weeks after onset of acute ICH
• Risk factors for VTE in patients with h/o ICH
• Stroke severity
• Weakness/changes in level of consciousness
• Female sex
• African Americans

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Venous Thromboembolism Prevention in the Setting
of Acute/Recent Intracranial Hemorrhage
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VTE Prevention
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VTE Prevention -Intermittent Pneumatic
Compression

• Treatment with IPC devices are associated with
  lower rate of DVT
• Should be instituted immediately
• CLOTS 3 Trial
• Open label, randomized study
• 2876 patients with stroke. 322 with hemorrhagic
  stroke
• IPC use was associated with reduced risk of DVT
  at 30 days-6.7 vs 17
• No major adverse events
• IPC devices are associated with a greater
  incidence of skin breaks

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VTE Prevention
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VTE Prevention-Anticoagulation
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VTE Prevention-Anticoagulation

• Meta-analysis of four studies
• Compared anticoagulation therapy with other
  treatments in patients with ICH
• Use of anti-coagulation was associated with a
  significant reduction in Pulmonary Embolism (1.7
  vs 2.9 P0.01)
• Use of anti-coagulation was associated with a
  non-significant reduction in DVT formation and
  mortality
• Non-significant increase in hematoma enlargement
• AHA/American Stroke Association
• After documentation of cessation of bleeding,
  low dose subcutaneous low molecular-weight
  heparin or unfractionated heparin may be
  considered for prevention of venous
  thromboembolism in patients with lack of mobility
  after 1 to 4 days from onset

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Anticoagulation and Thrombolytics in the
Management of PE
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Initial Anticoagulation in PE

• Subcutaneous LMWH
• Subcutaneous Fondaparinux
• Intravenous UFH

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Initial Anticoagulation in PE

• SC Low Molecular Weight Heparin (LMWH)
• Now considered better initial agent over UFH for
  most hemodynamically stable patients.
• Secondary to multiple randomized trials and
  meta-analyses showing
• Lower mortality
• Fewer recurrent thromboembolic events
• Less major bleeding events
• Non-superior to Fondaparinux.
• Monitoring none required in most patients.

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Initial Anticoagulation in PE

• SC Fondaparinux
• Recommended for most hemodynamically stable
  patients.
• Based on multiple studies against IV UFH
• Same effects on mortality, recurrent
  thromboembolism, major bleeding.
• Advantages over IV UFH
• Once or twice daily administration
• Fixed dose
• Less thrombocytopenia
• No monitoring necessary in most patients

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Initial Anticoagulation in PE

• IV Unfractionated Heparin (IV UFH)
• No longer preferred agent for stable acute PE.
• Preferred Indications
• Persistent hypotension
• Increased risk of bleeding
• Thrombolysis being considered
• Concern about subcutaneous absorption
• Renal failure
• Obese patients
• Monitoring
• aPTT

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Role of Thrombolytics in PE

• Agents
• tPA
• Naturally occurring enzyme
• Binds fibrin to enhance plasminogen activation
• Streptokinase
• Polypeptide derived from beta-hemolytic strep
• Binds to plasminogen to activate plasmin
• Urokinase
• Occurs naturally in urine
• Plasminogen activator

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Role of Thrombolytics in PE

• Indications
• Persistent hypotension lt90 mmHg SBP or decrease
  in SBP gt/ 40mmHg from baseline.
• Potential Indications
• Severe hypoxemia
• Large V/Q mismatch
• Extensive clot burden
• RV dysfunction
• Free-floating atrial/ventricular thrombus
• PFO
• Cardiopulmonary Resuscitation

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Role of Thrombolytics in PE
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Role of Thrombolytics in PE

• Purpose Compare echo parameters and clinical
  outcome of heparin vs thrombolysis in first 180
  days after SPE w/ RVD.
• Methods 72 consecutive patients w/ first episode
  SPE and symptoms lt6 hours w/ CT proven PE and
  echo proven RVD.
• Results Thrombolysis group showed significant
  early improvement in RV function and this
  improvement was still observed through the 180
  day follow up. Also noted to significant
  reduction in clinical events during
  hospitalization.

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Role of Thrombolytics in PE
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Role of Thrombolytics in PE
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Role of Thrombolytics in PE

• Contraindications
• Intracranial neoplasm
• Intracranial surgery/trauma (lt 2 months)
• Active or recent internal bleeding (lt 6 months)
• Hx Hemorrhagic CVA
• Non-hemorrhagic stroke (lt 2 months)
• Bleeding diathesis
• Uncontrolled HTN (gt200 sbp/110 dbp)
• Surgery (lt 10 DAYS)
• Thrombocytopenia ( lt 100, 000)

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Embolectomy in PE
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Embolectomy in PE

• Embolectomy
• Should be considered when patient presentation
  warrants thrombolysis but therapy either fails or
  is contraindicated.
• Can be done surgically or via catheter
• Dependent upon availabilities and expertise at
  each individual institution.

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Embolectomy in PE

• Surgical Embolectomy
• Requires cardiopulmonary bypass.
• Has been prompted by
• failure of initial thrombolysis
• echo evidence of thrombus in
• R atrium
• R ventricle
• PFO
• Cardiac arrest pre-surgery can be predictive of
  mortality during surgery by one small study of 55
  pts
• 97 survival of those w/o
• 75 survival of those w/

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Embolectomy in PE

• Catheter Embolectomy
• Rheolytic (ie. AngioJet)
• Injection of pressurized saline to macerate
  emboli. Fragments collected via exhaust lumen.
• Requires venous cut down.
• Rotational
• Cardiac catheter equipped with a rotating device
  that continuously fragments/aspirates pieces of
  the thrombus.
• Does not require venous cut down.
• Suction
• Uses a large lumen catheter to apply direct
  negative pressure suction w/ an aspiration
  syringe.
• Fragmentation
• Thrombus disruption via manually rotating a
  standard pigtail catheter or balloon angio
  catheter against the thrombus.

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Embolectomy in PE
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Advanced Interventions Catheter Directed
Intervention
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Advanced InterventionsCatheter Directed
Intervention

• Indications for catheter based intervention in
  the setting of acute massive PE should include
  one of the following
• Arterial hypotension. defined as systolic
  arterial pressure 90 mm Hg, a drop in systolic
  arterial pressure 40 mm Hg for 15 minutes, or
  ongoing administration of catecholamine for the
  treatment of systemic arterial hypotension
• Cardiogenic shock with peripheral hypoperfusion
  and hypoxia
• Circulatory collapse, including syncope or need
  for cardiopulmonary resuscitation
• Echocardiographic findings indicating right
  ventricular dilatation and/or pulmonary
  hypertension
• Subtotal or total filling defect in the left
  and/or right main pulmonary artery determined by
  chest computed tomography (CT) scan or by
  conventional pulmonary angiography or
• Widened arterial-alveolar O2 gradient (gt 50 mm
  Hg).

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Advanced InterventionsCatheter Directed
Intervention
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Advanced InterventionsCatheter Directed
Intervention

• Meta-analysis examining 594 patients from 35
  studies
• Patients with acute massive PE treated with
  modern CDT
• Clinical success defined as stabilization of
  hemodynamics, resolution of hypoxia, and survival
  
• Pooled clinical success rate of CDI was 86.5
• Risk of minor and major complications were 7.9
  and 2.4 respectively

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Advanced Interventions-EKOS

• Ultrasound accelerated catheter directed
  thrombolysis
• Delivered via an infusion catheter that emits
  ultrasound energy to accelerate the thrombolytic
  cascade
• This is achieved by using the EkoSonic
  Endovascular System that is manufactured by the
  EKOS corporation
• Acoustic energy leads to breakdown of fibrin and
  increases fibrin porosity without causing distal
  embolization
• This facilitates penetration of thrombolytic drugs

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Advanced Interventions-EKOS
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Advanced Interventions-EKOS

• Patients were randomized into EKOS group and
  conventional CDI group who received either tPA or
  urokinase
• Complete thrombolysis More than 90 thrombus
  removal
• Near complete lysis 75-90 removal of thrombus
• Partial lysis 50-75 removal
• Follow-up pulmonary angiography performed 12-48
  hours after initiation of intervention to
  determine progression of thrombus disruption

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Advanced Interventions-EKOS
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Advanced Interventions-EKOS
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Advanced Interventions-EKOS

• 59 patients with acute main or lower lobe PE and
  RV/LV ratio of gt1
• Randomized to receive either ultrasound assisted
  catheter directed thrombolysis vs. unfractionated
  heparin alone
• Primary outcome was the difference in RV/LV ratio
  from baseline to 24 hours
• Safety outcomes included death, major or minor
  bleeding, and recurrent VTE at 90 days

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Advanced Interventions-EKOS
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Advanced Interventions-EKOS

• Significant reduction in RV/LV ratio in study
  group
• Significant reduction in pulmonary artery and
  right atrial pressures
• Significant increase in cardiac index
• No recurrent VTE or hemodynamic decompensation
• No major bleeding complications. 3 patients (10)
  experienced minor bleeding complications

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Advanced Interventions-EKOS
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Advanced Interventions-EKOS
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Advanced Interventions-EKOS
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References

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  S, Okada Y. Deep venous thrombosis after acute
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• Christensen MC, Dawson J, Vincent C. Risk of
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  hemorrhage according to ethnicity. Adv Ther.
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• Skaf E, Stein PD, Beemath A, Sanchez J,
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• Orken DN, Kenangil G, Ozkurt H, Guner C, Gundogdu
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• CLOTS (Clots in Legs Or sTockings after Stroke)
  Trials Collaboration, Dennis M, Sandercock P,
  Reid J, Graham C, Forbes J, Murray G.
  Effectiveness of intermittent pneumatic
  compression in reduction of risk of deep vein
  thrombosis in patients who have had a stroke
  (CLOTS 3) a multicentre randomised controlled
  trial. Lancet. 2013382(9891)516.
• Paciaroni M, Agnelli G, Venti M, Alberti A,
  Acciarresi M, Caso V. Efficacy and safety of
  anticoagulants in the prevention of venous
  thromboembolism in patients with acute cerebral
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  studies. J Thromb Haemost. 20119(5)893