Hematology and Oncology Book

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Thrombolysis in Massive Pulmonary EmbolismAka: Pulmonary Embolism Thrombolysis, PE Thrombolysis

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  1. See Also
    1. Thrombolytic
    2. Pulmonary Embolism
    3. Pulmonary Embolism Management
  2. Indications
    1. Massive Pulmonary Embolism
    2. Associated findings with PE
      1. Absolute indications
        1. Hypotension
        2. Systemic hypoperfusion
      2. Relative indications
        1. Right ventricular dysfunction
        2. Pulmonary Hypertension
        3. Extensive Deep Vein Thrombosis
        4. Prevent recurrent Pulmonary Embolism
  3. Contraindications
    1. See Thrombolytic Contraindication
  4. Efficacy
    1. Only benefit may be in massive Pulmonary Embolism
      1. Thrombolysis offers faster clot lysis than Heparin
      2. Short-term better pulmonary artery perfusion
      3. Benefit is in first 24-48 hours
    2. Thrombolysis longterm outcomes are similar to Heparin
      1. No difference in mortality
      2. No difference in Pulmonary Embolism resolution
      3. No difference in recurrent PE
    3. Local or directed Thrombolysis offers no benefit
    4. References
      1. (1974) JAMA 229:1606
      2. Levine (1990) Chest 98:1473
      3. Dalla-Volta (1992) J Am Coll Cardiol 20:520
  5. Protocol
    1. General
      1. Indicated within 14 days of severe PE onset
      2. Outcomes between agents are similar at 24 hours
      3. Meyer (1992) J Am Coll Cardiol 19:239
    2. Agents
      1. T-PA (Alteplase)
        1. T-PA 100 mg peripheral infusion over 2 hours
      2. Streptokinase
        1. Load: 250,000 units over 30 minutes
        2. Maintenance: 100,000 units per hour for 24 hours
      3. Urokinase
        1. Load: 4400 units/kg over 10 minutes
        2. Maintenance: 4400 units/kg per hour for 12-24 hours
    3. Monitoring
      1. Obtain PTT after Thrombolytic infusion and q4 hours
      2. Start Heparin if PTT falls below 2.5x normal control
      3. Maintain PTT 1.5 to 2.5 times normal
  6. Complications
    1. See Complications in Thrombolysis
  7. References
    1. Almoosa (2002) Am Fam Physician 65(6):1097

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