PE/DVT discussion

[Tiger26]

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agreed. reductions in the development of right sided failure and pulmonary hypertension are clinically significant outcomes in my opinion

Yeah the thing I'd care about is whether I'd be able to walk to the end of the driveway or not--minimizing right heart failure through the reduction of clot burden seems to do that

 

[Rendar5]

Kinda hard to walk down that driveway if you are hemiplegic

 

[Tiger26]

Kinda hard to walk down that driveway if you are hemiplegic

True--strikes and gutters, ups and downs.

Though the bleed rate from what I know for PE is similar to that of lyrics for MI, which we all recognize as being safe in terms of risks/benefits. If you think about why people bleed into their heads from stroke, it's because you've put tpa into an already injured brain.

 

[southerndoc]

Submassive --> Cath directed thrombolytics. Increasing evidence supports this, with overall mortality rates down from 3% to <1% as well as increased functional status at 6 months and decreased incidents of pulmonary hypertension. 2 trials currently in progress to study these later endpoints. Takes days to get heparin gtt to have an effect on the clots. TNK is another option if you don't have access.

Submassive for us is SBP <90 for 15 minutes or >40 drop in their normal SBP for 90 minutes, BNP>500, Trop >.1, or any evidence of right heart strain on CT or ECHO. All of these guys get thrombolytics. It's been a big discussion here between ED, IR, and ICU and this is what we've decided to do. Goal PTT 65-80.

Can you point to the evidence that catheter directed lysis improves mortality? Curious if new research has came out since I reviewed this a few years ago.

 

[Bostonredsox]

Can you point to the evidence that catheter directed lysis improves mortality? Curious if new research has came out since I reviewed this a few years ago.

My understanding was that it doesnt. It has no benefit over systemic TPA infusion and has higher rates of procedural complications.

 

[Rendar5]

True--strikes and gutters, ups and downs.

Though the bleed rate from what I know for PE is similar to that of lyrics for MI, which we all recognize as being safe in terms of risks/benefits. If you think about why people bleed into their heads from stroke, it's because you've put tpa into an already injured brain.

just playin devil's advocate. half dose lytics is interesting though.

 

[Hernandez]

just playin devil's advocate. half dose lytics is interesting though.

The half dose lytics article from 4 years ago was one of the more interesting articles to come out on lytics in PE, if you ask me.

 

[Apollyon]

The half dose lytics article from 4 years ago was one of the more interesting articles to come out on lytics in PE, if you ask me.

Can you expand on that a bit? I am asking you.

What was interesting?

 

[Hamhock]

True--strikes and gutters, ups and downs.

Though the bleed rate from what I know for PE is similar to that of lyrics for MI, which we all recognize as being safe in terms of risks/benefits.

Yup.

QFT.

If only we could say the same thing for iCVA.

HH

 

[Hamhock]

If you use tpa for iCVA, I would:

(1) strongly suggest you review the tpa literature...or the summary by David Newman

(2) more confidently push alteplase for massive PE; and even sub-massive PE

HH

 

[med2UCC]

TPA is standard of care at our shop,to the point where I recently had to respond to a pt complaint that I didn't give it to a 3 day old CVA. Pts and their families expect it. I think this has gone nowhere but am not really sure as once I write my response I get no further feedback until I get either the college complaint or the hospital reprimand. We have no choice about giving it unless we are outside the window or have a CT confirmed bleed. Our neurologists are firmly behind it - but don't come see the patient until the next weekday morning.
M