How to prevent fatal pulmonary embolism
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The document discusses the prevention of fatal pulmonary embolism (PE) in Australia, highlighting the significant incidence of venous thromboembolism (VTE) and its contribution to hospital deaths. It emphasizes the need for a multimodal prevention strategy, including the use of mechanical prophylaxis and cautious anticoagulation management, while discouraging reliance on INR or APTT as sole indicators for risk. Additionally, it addresses the use of IVC filters for prophylaxis under specific circumstances and advocates for structured protocols to improve patient outcomes.
How to prevent fatal pulmonary embolism
- 1. How to Prevent Fatal Pulmonary Embolism (PE)? Kwok M. Ho Royal Perth Hospital, University of Western Australia & Murdoch University
- 2. Disclosures WA Health & Raine Medical Research Foundation through the Raine Clinical Research Fellowship Cardinal HealthTM DVT Advisory Board Member & Have received competitive research grant from Haemonetics®
- 3. Significance of VTE VTE incidence of 7.4 per 10,000/year in Australia, Up to 7% of all deaths in Australian hospitals are related to VTE, ANZICS CORE → Acute PE ~ 1% of all emergency ICU admissions: >20% required IPPV, 4.2% had cardiac arrest prior to ICU adm & mortality was high (15%) Chong BH, et al. MJA 2008;189:134-5. Access Economics. The burden of venous thromboembolism in Australia. Report for the Australia and New Zealand Working Party on the Management and Prevention of Venous Thromboembolism. May 2008; Thrombosis & Haemostasis 2013;109:272-9.
- 4. Inevitable or Preventable ? Die with PE Die from PE
- 5. Die with PE Die from PE Should we believe so?
- 6. 1st Reason
- 7. The delivery of medical care is to do as much NOTHING as possible
- 8. 2nd Reason
- 9. If anything goes wrong, just blame the patient 3rd Reason if in doubt, blame the patients ….
- 10. Die with PE Die from PE Ann Vasc Surg 2018;pii:S0890- 5096(18)30218-8. Ann Thorac Med 2017;12:282-9. Chest 2011;140:1436-46. Br J Anaesth 2010;105:596-602.
- 12. Guilt Shame (in a M & M meeting) Reflect, Research & Change in Practice Implement Changes in the System
- 13. Guilt Shame (in a M & M meeting) Reflect, Research & Change in Practice Implement Changes in the System
- 14. The ‘holes’ vary between different patients / systems & can change within the SAME patients with time
- 16. Root Cause Analysis – the Holes in Failure to Prevent Failure to Diagnose Failure to Treat
- 17. Maximise Prevention Mechanical prophylaxis (IPC > TEDS) is better than no prophylaxis IPC Circulation 2013;128:1003-20 Lancet 2013;382:516-24
- 18. Maximise Prevention Auto- anticoagulation (↑INR or aPTT) ≠ Not at Risk Anaesth & Intensive Care 2017;45:166-7 Anaesth Intensive Care 2013;41:322-7 NO !
- 19. Maximise Prevention INR or aPTT does not tell you the whole story about clots or bleeding Anaesth & Intensive Care 2017;45:166-7 Anaesth Intensive Care 2013;41:322-7 90.080.070.060.050.040.030.0 TEG maximum amplitude (MA) (mm) 60 50 40 30 20 10 0 Count YES NO VTE Odds ratio for VTE with a prothrombotic TEG result (MA >72mm or angle >74 degrees) = 11.8, 95% CI: 3.8-37; p=0.001 INR >1.5, aPTT >40s or PLT <150 can still be prothrombotic on TEG & developed VTE
- 20. Maximise Prevention UFH / LMWH may be safer than you think, but also less effective than you think Louis SG, et al. J Trauma Acute Care Surg 2014;76:937-43; Connelly CR, et al. JAMA Surg 2016;151:e162069
- 21. Fatal PE occurred in >5% in a large series of adult autopsy study; 37-64% undiagnosed before death Alikhan R, et al. J Clin Pathol 2004; Winters B, et al. BMJ Qual Saf 2012. So, don’t be shy to make early diagnose
- 22. Contrast-induced nephropathy (CIN) risk goes up with the risk of death from PE ∴ Benefits of a CTPA scan are almost always ˃ risk of CIN in ICU J intensive care 2018;6:3 PE kills before AKI from CIN
- 23. To anti-coagulate - UFH/LMWH To break – rotating pigtail catheter To bypass – ECMO To lyse - systemic vs regional To remove - surgically To suck - Aspirex1 Aspiration Thrombectomy Catheter Important to ‘Protocolise’ it (before crisis occurs) based on multidisciplinary agreement & local expertise Cardiovasc Diagn Ther 2016;6:651-61; J Intensive Care 2018;6:16
- 24. To lyse: 1. All-cause mortality: 2.2% vs 3.9% (vs anticoagulants) NNT = 59 2. Major bleeding: 9.2% vs 3.4% NNH = 18 3. ICH: 1.5% vs 0.2% NNH = 78 JAMA 2014;311:2414-21 To anti-coagulate: 1. UFH vs LMWH vs DOAC: Depends of CVS instability / body weight / bleeding risk 2. Aim at a high aPTT for the 1st 24hrs (~ 90-120s) 3. T1/2 = 90min (minimum Q6H aPTT initially & earlier after bolus top-up)
- 26. =
- 27. = Ann Vasc Surg 2018 Mar 8. pii: S0890-5096(18)30218-8.
- 28. = Median awards worth of US$1,092,500 !!!
- 29. = Including not using it as 10 prophylaxis
- 30. Increasing use of retrievable IVC filters for 10 VTE prophylaxis in trauma patients
- 31. Using IVC filter for Primary Prophylaxis vs PE in pts with contraindication to anticoagulant prophylaxis ? Eastern Association for the Surgeons of Trauma (EAST) American College of Chest Physicians (ACCP) American College of Radiology (ACR)
- 32. JAMA Surg 2016: More observational studies are needed …. seriously?
- 34. How about use of IVC filter for PRIMARY prophylaxis vs PE in patients with contraindication to anticoagulant prophylaxis??
- 35. ≠ Panacea
- 36. Setting a higher bar for using IVC filter for 10 prophylaxis
- 37. Summary A multimodal approach to maximize prevention Don’t rely on INR or aPTT alone to guide anticoagulant prophylaxis Excluding PE by CTPA is more important than CIN Aggressive heparinization initially Protocolize advanced therapies IVC filter not to be routinely used for 10 prophylaxis (with some exceptions)
- 38. The delivery of “good medical care” is to give patients greasy delicious food, whatever they want from their Google research, & NO THROMBOPROPHYLAXIS Modified from http://gomerblog.com/2016/11/2016-updated-house-of-god-rules/ : the alternative advices?
- 39. A multimodal approach is needed to prevent fatal PE but following the Laws of the House of God is not part of it
- 40. Thank you very much for your attention Slide request to kwok.ho@health.wa.gov.au