Pulmonary embolism in the intensive care unit

DVT and PE result in substantial morbidity and mortality in hospitalized patients. ICU patients exhibit a wide array of underlying medical or surgical diseases combined with prolonged immobility. Prompt recognition of risk factors with institution of appropriate prophylaxis is crucial in the ICU setting. Because symptoms and signs as well as radiographic findings are nonspecific in PE, constant vigilance is warranted in the ICU. Symptoms and signs compatible with PE that are otherwise unexplained, particularly when associated with an elevated A-aDO2, mandate prompt investigation with V/Q scanning. If this method is nondiagnostic and clinical suspicion is reasonably high, pulmonary arteriography is warranted. PE is frequently superimposed on other underlying cardiopulmonary diseases, such as chronic obstructive lung disease, pneumonia, or congestive heart failure, and should always be considered in the setting of acute deterioration. Documentation of DVT in the setting of unexplained respiratory symptoms and signs may serve as presumptive evidence for PE. New diagnostic modalities, such as intravascular ultrasound and MRI, may ultimately serve to enhance the diagnostic yield for VTE. Anticoagulation remains the mainstay of therapy for DVT and PE. Low molecular weight heparin has recently been approved for use as DVT prophylaxis in patients undergoing total hip replacement and will likely significantly impact on the treatment of venous thromboembolism. When hemorrhagic complications prevent effective administration of anticoagulation, placement of an IVC filter is indicated. This technique may also be effective in the setting of massive PE to prevent further emboli. Thrombolytic therapy is appropriate in the setting of PE associated with hemodynamic compromise in the absence of absolute contraindications. Future clinical trials may facilitate diagnosis, therapy, and prevention of this disease.

Duke Scholars

Author William J. Fulkerson Jr. Medicine, Pulmonary, Allergy, and Critical Care Medicine