Varis operasyonu sonrası masif pulmoner embolide trombolitik tedavi
Küçük Resim Yok
Tarih
2011
Dergi Başlığı
Dergi ISSN
Cilt Başlığı
Yayıncı
Erişim Hakkı
info:eu-repo/semantics/openAccess
Özet
Varis operasyonu sonrası derin ven trombozu (DVT) gelişmesi ve buna sekonder masif pulmoner emboli (PE) oldukça nadirdir. Masif PE sonrası senkop, sistemik arteriyel hipotansiyon, kardiyojenik şok veya kardiyak arest gelişen hastalar en yüksek riskli grubu oluşturmakta ve hemodinamik olarak stabil olmayan hastalarda mortalite %15-25 civarında tahmin edilmektedir. Kardiyak arest gelişen hastalarda %50nin üzerinde mortalite olduğu bildirilmiştir. Masif pulmoner emboliye sekonder kardiyak arrest sonrası yapılan kardiyopulmoner resüsitasyon sırasında tromboliz uygulanması yeni ve göreceli olarak güvenilir bir tedavi seçeneği olarak sunulmaktadır. Kliniğimizde varis operasyonu sonrası geçirdiği masif pulmoner emboliye sekonder kardiyak arest gelişen 50 yaşında bayan hastaya en muhtemel sebebin pulmoner emboli olacağı düşünülerek resüsitasyon ile eş zamanlı trombolitik tedavi uy- gulandı. Yaklaşık 2 saat süren resüsitasyon sonrası hastanın hemodinamisi stabilize edildi. Yoğun bakım ünitesinde 21 gün süren takip sürecinden sonra herhangi bir nörolojik sekel olmadan taburcu edildi. Kardiyak areste sebep olan masif pulmoner emboli acilen müdahale edilmesi gereken ciddi bir komplikasyondur. Kardiyak resüsitasyon sırasında eş zamanlı tromboliz uygulanması kısa sürede tedavinin başlanmasını sağlamakta ve resüsitasyonun başarılı olmasında önemli rol oynamaktadır. Özellikle PE tanısının kuvvetle muhtemel olduğu hastalarda hızla trombolitik tedavi başlanması görece- li olarak güvenli bir tedavi seçeneği olup, hayat kurtarıcı olabilmektedir. Trombolitik uygulamaya alternatif tedaviler cerrahi embolektomi, kateter- yardımlı embolektomi ve inferior vena kavaya filtre yerleştirilmesi olabilir ve trombolitik tedaviye kontraendikasyon olması veya başlangıç tedavisine yanıt alınamaması durumunda düşünülmelidirler.
Development of deep venous thrombosis (DVT) and pulmonary embolism (PE) after varicose vein surgery is a rare complication. Once developed, acute massive pulmonary embolism (PE) carries an exceptionally high mortality rate. Many deaths occur in hemodynamically unstable patients and the estimated mortality for inpatients with hemodynamic instability is between 15% and 25%. Thrombolysis during cardiopulmonary resuscitation may represent a new and relatively safe therapeutic option during resuscitation after cardiac arrest due to acute fulminant pulmonary embolism. We used thrombolysis during cardiopulmonary resuscitation for a 50 year old female patient who developed cardiac arrest during mobilization one day after varicose vein surgery. She had varicose veins on the pretibial area and venous Doppler examination revealed grade III-IV insufficiency of the great saphenous vein without any deep venous pathology. She underwent stripping and extraction of venous dilatations with spinal anesthesia. Upon devel- opment of cardiac arrest, PE was suspected to be the most probable underlying pathology and thrombolytic treatment was started (1.500.000 units of streptokinase) as soon as possible during resuscitation. After 2 hours of successful resuscitation, the patient was stabilized with the of use of vasopres- sors, inotropes, pulmonary artery (PA) vasodilators and mechanical ventilation. Thorax CT showed no thrombus in the main pulmonary arteries, but a possible infarct area at the left upper lobe. Cranial CT after resuscitation did not reveal any pathology. She stayed in intensive care unit for 21 days and was discharged without any neurologic sequela. She has been followed without any problems for the last 20 months. Acute massive pulmonary embo- lism (PE) carries an exceptionally high mortality rate and should be treated aggressively. The majority of deaths from acute PE are due to RV pressure overload and subsequent RV failure. The goal of fibrinolysis in acute PE is to rapidly reduce RV afterload and avert impending hemodynamic collapse and death. Thrombolytics during resuscitation also enable immediate treatment and play an important role in the success of resuscitation. Tradition- ally, thrombolysis during cardiopulmonary resuscitation has been contraindicated because of the risk of life-threatening bleeding complications. Early clinical experience and results of several trials suggest that the risk of bleeding is lower and the overall clinical benefit is greater than previously thought. Initiation of thrombolysis immediately during resuscitation after cardiac arrest, especially secondary to PE, represents a relatively safe and life saving treatment. If the results of an international randomised, controlled clinical multicentre trial presently underway confirm the previous clinical findings, thrombolysis during cardiopulmonary resuscitation could become an important part of future cardiopulmonary resuscitation algorithms. For patients with a contraindication to anticoagulation and thrombolytic therapy, insertion of inferior vena cava filters, surgical embolectomy and catheter- based therapies are options.
Development of deep venous thrombosis (DVT) and pulmonary embolism (PE) after varicose vein surgery is a rare complication. Once developed, acute massive pulmonary embolism (PE) carries an exceptionally high mortality rate. Many deaths occur in hemodynamically unstable patients and the estimated mortality for inpatients with hemodynamic instability is between 15% and 25%. Thrombolysis during cardiopulmonary resuscitation may represent a new and relatively safe therapeutic option during resuscitation after cardiac arrest due to acute fulminant pulmonary embolism. We used thrombolysis during cardiopulmonary resuscitation for a 50 year old female patient who developed cardiac arrest during mobilization one day after varicose vein surgery. She had varicose veins on the pretibial area and venous Doppler examination revealed grade III-IV insufficiency of the great saphenous vein without any deep venous pathology. She underwent stripping and extraction of venous dilatations with spinal anesthesia. Upon devel- opment of cardiac arrest, PE was suspected to be the most probable underlying pathology and thrombolytic treatment was started (1.500.000 units of streptokinase) as soon as possible during resuscitation. After 2 hours of successful resuscitation, the patient was stabilized with the of use of vasopres- sors, inotropes, pulmonary artery (PA) vasodilators and mechanical ventilation. Thorax CT showed no thrombus in the main pulmonary arteries, but a possible infarct area at the left upper lobe. Cranial CT after resuscitation did not reveal any pathology. She stayed in intensive care unit for 21 days and was discharged without any neurologic sequela. She has been followed without any problems for the last 20 months. Acute massive pulmonary embo- lism (PE) carries an exceptionally high mortality rate and should be treated aggressively. The majority of deaths from acute PE are due to RV pressure overload and subsequent RV failure. The goal of fibrinolysis in acute PE is to rapidly reduce RV afterload and avert impending hemodynamic collapse and death. Thrombolytics during resuscitation also enable immediate treatment and play an important role in the success of resuscitation. Tradition- ally, thrombolysis during cardiopulmonary resuscitation has been contraindicated because of the risk of life-threatening bleeding complications. Early clinical experience and results of several trials suggest that the risk of bleeding is lower and the overall clinical benefit is greater than previously thought. Initiation of thrombolysis immediately during resuscitation after cardiac arrest, especially secondary to PE, represents a relatively safe and life saving treatment. If the results of an international randomised, controlled clinical multicentre trial presently underway confirm the previous clinical findings, thrombolysis during cardiopulmonary resuscitation could become an important part of future cardiopulmonary resuscitation algorithms. For patients with a contraindication to anticoagulation and thrombolytic therapy, insertion of inferior vena cava filters, surgical embolectomy and catheter- based therapies are options.
Açıklama
Anahtar Kelimeler
Kalp ve Kalp Damar Sistemi
Kaynak
JAREM
WoS Q Değeri
Scopus Q Değeri
Cilt
1
Sayı
1
