critical care

Mortality Reaches 20% for Hospitalized Patients With High-Risk Pulmonary Embolism

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Worst outcomes for patients with hemodynamic collapse

A computer rendering of a thrombus in a blood vessel.

Mortality rates were high among patients with high-risk pulmonary embolism (PE), with the worst outcomes in those with hemodynamic collapse, according to a retrospective analysis of the Pulmonary Embolism Response Team (PERT) Consortium Registry.

In nearly 5,800 patients, in-hospital mortality occurred over five times more frequently among those with high-risk PE compared with those with intermediate-risk PE (20.6% vs 3.7%, P<0.001), reported Jay Giri, MD, MPH, of the Perelman School of Medicine at the University of Pennsylvania in Philadelphia, and co-authors.

Similarly, the risk for major bleeding was also higher among high-risk PE patients versus intermediate-risk PE patients (10.5% vs 3.5%, P<0.001), they noted in the Journal of the American College of Cardiologyopens in a new tab or window.

“In comparison with previous data reported in high-risk PE patients, several patterns emerge,” Giri and team wrote. “First, our work confirms that high-risk PE patients are the predominant driver of observed short-term mortality in hospitalized PE patients.”

“While prior observational studies of high-risk PE patients have demonstrated short-term mortality ranging from 30% to 50%, our study demonstrated a somewhat lower overall mortality rate of 20.6% in all high-risk patients,” they continued. “This could be due to more complete capture of the entire high-risk spectrum in this registry, technological improvements in PE care, and/or improved care delivery methods in experienced PERT centers.”

In an editorial commentopens in a new tab or window, Behnam N. Tehrani, MD, of Inova Schar Heart and Vascular in Falls Church, Virginia, and co-authors noted that PE remains one of the top causes of cardiovascular death in the U.S., but more research is needed to improve risk assessment models.

The findings from this study “should serve as an impetus for universally accepted definitions for high-risk PE and the pursuit of novel metrics to elucidate signals of efficacy, including durable changes in hemodynamics, metabolic measures of tissue perfusion, and echocardiographic and proteomic-based predictors of survival and myocardial recovery,” they wrote.

In the study, multivariable regression analysis showed that there were a number of factors associated with in-hospital mortality:

  • Vasopressor use: OR 4.56, 95% CI 3.27-6.38, P<0.01
  • Extracorporeal membrane oxygenation (ECMO) use: OR 2.86, 95% CI 1.12-7.30, P=0.03
  • Identified clot-in-transit: OR 2.26, 95% CI 1.13-4.52, P=0.02
  • Malignancy: OR 1.70, 95% CI 1.13-2.56, P=0.01

Giri and colleagues also found that patients presenting with catastrophic PE had greater in-hospital mortality than their non-catastrophic counterparts (42.1% vs 17.2%, P<0.001), and ECMO (13.3% vs 4.8%, P<0.001) and systemic thrombolysis (25% vs 11.3%, P<0.001) were used more commonly in catastrophic PE.

Data for this study were taken from the PERT Consortium Registry, which includes patients from all 35 active U.S. registry sites admitted from Oct. 16, 2015 to April 8, 2022. Of the 5,790 patients in the study, 1,442 presented with high-risk PE and 2,976 presented with intermediate-risk PE.

Approximately half of the patients were men, and the average patient age was 63 years. Over half of the patients in both the high- and intermediate-risk cohorts were white.

High-risk PE patients were defined as those who, on initial hospital presentation, experienced hemodynamic collapse, hypotension, sustained systolic blood pressures <90 mm Hg, or the need for vasopressor support. Catastrophic patients additionally needed to have hemodynamic collapse that ultimately necessitated use of high-dose vasopressors due to concerns for impending cardiac arrest or those experiencing cardiac arrest with or without cardiopulmonary resuscitative efforts.

Intermediate-risk patients were defined as having systolic blood pressures >90 mm Hg, as well as evidence of right ventricular strain and/or biomarker abnormalities.

Giri and team noted that use of the PERT Consortium Registry may have excluded patients admitted to the hospital for PE who did not have previous consultations associated with the registry. Other potential limitations to the study included the fact that patients in the registry may have spent less time in the intensive care unit and may have had a shorter length of stay due to utilization of advanced therapies.

Ultrasound-Guided Central Venous Catheter Placement: First Things First

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We recommended a “six-step-approach”. Because US is still used infrequently for CVC insertion [3, 4] we aimed to provide a basic, pragmatic, and evidence-based concept applicable in clinical routine rather than making the approach unnecessarily complicated.

We discussed that a disadvantage of the short-axis/out-of-plane approach is that not the entire needle but only an echogenic point (that must not be the needle tip) is visualized [2].

Experienced users might perform additional steps during US-guided CVC placement, e.g., double-checking that the needle is not localized over the adjacent artery before entering the target vein (long-axis/in-plane approach). Although this additional step might further improve procedural quality in the hands of experts, it is not backed up by study data and necessitates transiently abandoning the view of the needle and the target vein. This “angle change” of the US probe to check the adjacent artery before puncturing the vein only makes sense if the artery is anatomically located equally deep or deeper (and not more superficial) compared to the vein.

US can provide important information about the correct position of the guidewire [2]. As suggested, one can check the ipsilateral subclavian vein (for internal jugular vein CVCs) or the internal jugular vein (for subclavian CVCs) to exclude misdirection of the guidewire. Consequently, following this line of argument, one should also exclude misdirection of the guidewire in the contralateral veins and the thyroid veins. It needs to be emphasized, however, that strictly aseptic conditions need to be ensured during all additional steps; this might even require a second operator excluding misdirection of the guidewire in different veins with an additional non-sterile US probe. Alternatively, one could confirm the tip of the guidewire in the superior vena cava/the right atrium using transthoracic echocardiography.

Although not part of our basic recommendations, experienced operators can use US to confirm the correct position of the CVC (direct visualization of the CVC tip or indirect identification of the CVC tip by rapid injection of saline and imaging of turbulent flow in the right atrium or vascular structures) and to exclude iatrogenic pneumothorax [5].

US offers various opportunities to improve the quality and safety of CVC placement, but to advocate and promote US as the standard of care for CVC placement in anesthesiology and critical care our recommendations need to be straightforward!