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      Decompressive laparotomy for a patient on VA-ECMO for massive pulmonary embolism that suffered traumatic liver laceration after mechanical CPR

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          Abstract

          Massive pulmonary embolism (PE) is an embolus sufficiently obstructing pulmonary blood flow to cause right ventricular (RV) failure and hemodynamic instability. We have utilized veno-arterial extracorporeal membrane oxygenation (VA-ECMO) for early and aggressive intervention for massive PE patients. We present a case of a 61-year-old female placed on VA-ECMO for a massive PE while presenting in cardiac arrest and receiving mechanical cardiopulmonary resuscitation (CPR) via the LUCAS 2.0 device (Physio-Control Inc., Lund, Sweden). The patient suffered a severe liver laceration secondary to mechanical CPR and required a decompressive laparotomy. This case highlights that mechanical CPR during other interventions can lead to malposition of the device and could result in solid organ injury.

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          Management Strategies and Determinants of Outcome in Acute Major Pulmonary Embolism: Results of a Multicenter Registry

          Wolfgang Kasper, Stavros Konstantinides, Annette Geibel … (1997)
          The present study investigated current management strategies as well as the clinical course of acute major pulmonary embolism. The clinical outcome of patients with acute pulmonary embolism who present with overt or impending right heart failure has not yet been adequately elucidated. The 204 participating centers enrolled a total of 1,001 consecutive patients. The inclusion criteria were based on the clinical findings at presentation and the results of electrocardiographic, echocardiographic, nuclear imaging and cardiac catheterization studies. Echocardiography was the most frequently performed diagnostic procedure (74%). Lung scan or pulmonary angiography were performed in 79% of clinically stable patients but much less frequently in those with circulatory collapse at presentation (32%, p < 0.001). Thrombolytic agents were given to 478 patients (48%), often despite the presence of contraindications (193 [40%] of 478). The frequency of initial thrombolysis was significantly higher in clinically unstable than in normotensive patients (57% vs. 22%, p < 0.001). Overall in-hospital mortality rate ranged from 8.1% in the group of stable patients to 25% in those presenting with cardiogenic shock and to 65% in patients necessitating cardiopulmonary resuscitation. Major bleeding was reported in 92 patients (9.2%), but cerebral bleeding was uncommon (0.5%). Finally, recurrent pulmonary embolism occurred in 172 patients (17%). Current management strategies of acute major pulmonary embolism are largely dependent on the degree of hemodynamic instability at presentation. In the presence of severe hemodynamic compromise, physicians often rely on the findings of bedside echocardiography and proceed to thrombolytic treatment without seeking further diagnostic certainty in nuclear imaging or angiographic studies.
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            Massive pulmonary embolism.

            Nils Kucher, Elisa Rossi, Marisa De Rosa … (2006)
            Acute massive pulmonary embolism (PE) carries an exceptionally high mortality rate. We explored how often adjunctive therapies, particularly thrombolysis and inferior vena caval (IVC) filter placement, were performed and how these therapies affected the clinical outcome of patients with massive PE. Among 2392 patients with acute PE and known systolic arterial blood pressure at presentation, from the International Cooperative Pulmonary Embolism Registry (ICOPER), 108 (4.5%) had massive PE, defined as a systolic arterial pressure or =90 mm Hg. PE was first diagnosed at autopsy in 16 patients (15%) with massive PE and in 29 patients (1%) with non-massive PE (P<0.001). The 90-day mortality rates were 52.4% (95% CI, 43.3% to 62.1%) and 14.7% (95% CI, 13.3% to 16.2%), respectively. In-hospital bleeding complications occurred in 17.6% versus 9.7% and recurrent PE within 90 days in 12.6% and 7.6%, respectively (P<0.001). In patients with massive PE, thrombolysis, surgical embolectomy, or catheter embolectomy were withheld in 73 (68%). Thrombolysis was performed in 33 patients, surgical embolectomy in 3, and catheter embolectomy in 1. Thrombolytic therapy did not reduce 90-day mortality (thrombolysis, 46.3%; 95% CI, 31.0% to 64.8%; no thrombolysis, 55.1%; 95% CI, 44.3% to 66.7%; hazard ratio, 0.79; 95% CI, 0.44 to 1.43). Recurrent PE rates at 90 days were similar in patients with and without thrombolytic therapy (12% for both; P=0.99). None of the 11 patients who received an IVC filter developed recurrent PE within 90 days, and 10 (90.9%) survived at least 90 days. IVC filters were associated with a reduction in 90-day mortality (hazard ratio, 0.12; 95% CI, 0.02 to 0.85). In ICOPER, two thirds of the patients with massive PE did not receive thrombolysis or embolectomy. Counterintuitively, thrombolysis did not reduce mortality or recurrent PE at 90 days. The observed reduction in mortality from IVC filters requires further investigation.
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              Acute pulmonary embolism.

              Giancarlo Agnelli, Cecilia Becattini (2010)
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                Author and article information

                Journal
                Journal ID (nlm-ta): J Surg Case Rep
                Journal ID (iso-abbrev): J Surg Case Rep
                Journal ID (publisher-id): jscr
                Title: Journal of Surgical Case Reports
                Publisher: Oxford University Press
                ISSN (Electronic): 2042-8812
                Publication date Collection: October 2018
                Publication date (Electronic): 31 October 2018
                Publication date PMC-release: 31 October 2018
                Volume: 2018
                Issue: 10
                Electronic Location Identifier: rjy292
                Affiliations
                [1 ]Department of Surgery, University of New Mexico School of Medicine, 2211 Lomas Blvd NE, Albuquerque, NM, USA
                [2 ]Division of Vascular, University of New Mexico School of Medicine, 2211 Lomas Blvd NE, Albuquerque, NM, USA
                [3 ]Department of Critical Care, University of New Mexico School of Medicine, 2211 Lomas Blvd NE, Albuquerque, NM, USA
                Author notes
                Correspondence address. MSC 10 5610, 1 University of New Mexico, Albuquerque, NM 87131, USA. Tel: +1-804-252-1012; Fax: +1-505-272-0111; E-mail: SGuliani@ 123456salud.unm.edu
                Article
                Publisher ID: rjy292
                DOI: 10.1093/jscr/rjy292
                PMC ID: 6207845
                SO-VID: 871f271b-66d9-4d58-b418-f8fad624c48f
                Copyright © Published by Oxford University Press and JSCR Publishing Ltd. All rights reserved. © The Author(s) 2018.
                License:

                This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( http://creativecommons.org/licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@ 123456oup.com

                History
                Date received : 18 August 2018
                Date revision received : 22 September 2018
                Date accepted : 09 October 2018
                Page count
                Pages: 3
                Categories
                Subject: Case Report

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