Impact of Rescue-Thrombolysis during Cardiopulmonary Resuscitation in Patients with Pulmonary Embolism

Abstract

BackgroundCardiac arrest in patients with pulmonary embolism (PE) is associated with high morbidity and mortality. Thrombolysis is expected to improve the outcome in these patients. However studies evaluating rescue-thrombolysis in patients with PE are missing, mainly due to the difficulties of clinical diagnosis of PE. We aimed to determine the success influencing factors of thrombolysis during resuscitation in patients with PE.Methodology/Principal FindingsWe analyzed retrospectively the outcome of 104 consecutive patients with confirmed (n = 63) or highly suspected (n = 41) PE and monitored cardiac arrest. In all patients rtPA was administrated for thrombolysis during cardiopulmonary resuscitation. In 40 of the 104 patients (38.5%) a return of spontaneous circulation (ROSC) could be achieved successfully. Patients with ROSC received thrombolysis significantly earlier after CPR onset compared to patients without ROSC (13.6±1.2 min versus 24.6±0.8 min; p<0.001). 19 patients (47.5%) out of the 40 patients with initially successful resuscitation survived to hospital discharge. In patients with hospital discharge thrombolysis therapy was begun with a significantly shorter delay after cardiac arrest compared to all other patients (11.0±1.3 vs. 22.5±0.9 min; p<0.001).ConclusionRescue-thrombolysis should be considered and started in patients with PE and cardiac arrest, as soon as possible after cardiac arrest onset.

Part 10: Special Circumstances of Resuscitation

“…37,[45][46][47][48][49][50][51][52][53][54] There is no consensus on the ideal dose of thrombolytic therapy in PE-associated cardiac arrest. Contemporary examples of accelerated emergency thrombolysis dosing regimens for fulminant PE include alteplase 50 mg intravenous (IV) bolus with an option for repeat bolus in 15 minutes, or single-dose weight-based tenecteplase; thrombolytics are administered with or followed by systemic anticoagulation.…”

“…[55][56][57] Early administration of systemic thrombolysis is associated with improved resuscitation outcomes compared with use after failure of conventional ACLS. 46 Successful surgical and percutaneous mechanical embolectomy in cases of PE-related cardiac arrest have been reported in limited series. [58][59][60] Many of these patients developed cardiac arrest before or during embolectomy.…”

Thrombolysis after initially unsuccessful cardiopulmonary resuscitation in presumed pulmonary embolism

“…Since then, more than 100 cases of successful administration of thrombolysis in patients with confirmed or suspected PE during CPR have been published, when the thrombolysis was almost always used as a last resort [8]. Besides case series, clinical studies have also confirmed the effectiveness of thrombolysis [9,10]. However, currently, the use of thrombolysis in CA caused by PE has not been supported by prospective, randomized, controlled trials.…”

Emerging pharmaceutical therapies in cardiopulmonary resuscitation and post-resuscitation syndrome

“…[56][57][58] Thombolysis Humans No treatment benefit from routine use in OHCA patients. May be useful in selected patients with STEMI and pulmonary embolism [61][62][63] Neurotensin Animals Prolonged decrease of body temperature. 64 ATP-sensitive potassium channel activators.…”

“…Thereafter, only a few reports from retrospective cohorts of patients show possible benefits from thrombolytic therapy in certain subgroups of patients with pulmonary embolism and STEMI. 62,63 Thrombolytic therapy is indicated post-ROSC in patients with STEMI and no possibility for invasive reperfusion. 48 …”