Pulmonary Embolism in the ICU

Abstract

Acute pulmonary embolism (PE) is a common and potentially fatal disease with a variable clinical presentation, ranging from an asymptomatic to an unstable and life-threatening clinical presentation.

From a pathophysiological point of view, the weak link is the right heart. Right ventricle (RV) failure can have an early or late onset and has a high impact on patient’s outcome. In this context, echocardiography is becoming central in diagnosis and monitoring of PE.

A prompt diagnosis and initiation of therapy is critical to prevent death in the most severe forms of the disease. A multidisciplinary pulmonary embolism team can improve efficiency of PE diagnosis and treatment. Index of risk stratification has high specificity and is central, once the diagnosis of PE is confirmed, to predict long-term outcomes.

The initial approach to severe PE must focus on the early treatment of the embolus (i.e., anticoagulation, embolectomy, and thrombolysis) simultaneously to a respiratory and hemodynamic stabilization. Subsequently, the treatment strategy will be centered on the management of RV-failure. Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is a possible rescue therapy in severe PE that can be used as bridge-to-treatment, to facilitate mechanical thrombectomy.

In this section of the book, the reader will face three ICU cases of PE.