Annals of Thoracic Medicine Official publication of the Saudi Thoracic Society, affiliated to King Saud University
 
Search Ahead of print Current Issue Archives Instructions Subscribe e-Alerts Login 
Home Email this article link Print this article Bookmark this page Decrease font size Default font size Increase font size


 
ORIGINAL ARTICLE
Year : 2009  |  Volume : 4  |  Issue : 1  |  Page : 13-16
Outcome of patients with pulmonary embolism admitted to the intensive care unit


Respiratory Division, College of Medicine, King Saud University, Riyadh 11324, Saudi Arabia

Date of Submission16-Jul-2008
Date of Acceptance09-Sep-2008

Correspondence Address:
Ahmed BaHammam
Director Sleep Disorders Center, College of Medicine, Department of Medicine, King Saud University, P. O. Box 225503, Riyadh 11324
Saudi Arabia
Login to access the Email id


DOI: 10.4103/1817-1737.44779

PMID: 19561916

Rights and Permissions

   Abstract 

Background:Pulmonary embolism (PE) is an important cause of in-hospital mortality. Many patients are admitted to the intensive care unit (ICU) either due to hemodynamic instability or severe hypoxemia. Few reports have addressed the outcome of patients with PE; however, none were from ICUs in the Middle East.
Objectives:To describe the demographics, clinical presentation, risk factors and outcome of patients with PE admitted to the medical ICU and to identify possible factors associated with poor prognosis.
Materials and Methods:Data were collected retrospectively by reviewing the records of patients admitted to the medical ICU with primary diagnosis of PE between January 2001 and June 2007. Demographic, clinical, radiological and therapeutic data were collected on admission to ICU.
Results: Fifty-six patients (43% females) with PE were admitted to the ICU during the study period. Their mean age was 40.6 ± 10.6 years. Seven patients (12.5%) had massive PE with hemodynamic instability and 15 (26.8%) had submassive PE. The remaining patients were admitted due to severe hypoxemia. Recent surgery followed by obesity were the most common risk factors (55.4 and 28.6%, respectively). Four patients with massive PE received thrombolysis because the remaining three had absolute contraindications. Fatal gastrointestinal bleeding occurred in one patient post thrombolysis. Additionally, two patients with massive PE and five with submassive PE died within 72 h of admission to the ICU, resulting in an overall mortality rate of 14%. Nonsurvivors were older and had a higher prevalence of immobility and cerebrovascular diseases compared with survivors.
Conclusions: The mortality rate of patients with PE admitted to the ICU in our center was comparable to other published studies. Older age, immobility as well as coexistent cerebrovascular diseases were associated with a worse outcome.


Keywords: Intensive care unit, pulmonary embolism, thrombolytic agents


How to cite this article:
Al Otair H, Chaudhry M, Shaikh S, BaHammam A. Outcome of patients with pulmonary embolism admitted to the intensive care unit. Ann Thorac Med 2009;4:13-6

How to cite this URL:
Al Otair H, Chaudhry M, Shaikh S, BaHammam A. Outcome of patients with pulmonary embolism admitted to the intensive care unit. Ann Thorac Med [serial online] 2009 [cited 2020 Dec 3];4:13-6. Available from: https://www.thoracicmedicine.org/text.asp?2009/4/1/13/44779


Pulmonary embolism (PE) is a major health problem with a reported annual incidence of 0.5 per 1000 persons. [1] Despite recent advances in prophylactic, diagnostic and therapeutic modalities, it is still one of the important causes of hospital morbidity and mortality. [2],[3] This could be partly due to its nonspecific symptoms and scarcity of specific physical signs. Not infrequently, these patients require admission to the intensive care unit (ICU) due to hemodynamic instability or severe hypoxemia. In 2002, 101,000 patients with primary diagnosis of PE were admitted to acute care hospitals in the United States [4] with a case fatality rate of 15% at 3 months. [5] Previous reports have described the variable outcome of patients with PE with reported mortality rate ranging from 8.1% in stable patients to 25% in those with cardiogenic shock and 65% post cardiopulmonary resuscitation. [2],[6] Nevertheless, there are no published studies from Middle Eastern hospitals that assessed the outcome of PE in the ICUs. Therefore, we conducted this study to determine the outcome, risk factors, clinical characteristics and demographics of patients with PE admitted to the medical ICU at King Khalid University Hospital in Riyadh, Saudi Arabia, and to identify possible demographic and clinical factors associated with poor outcome.


   Materials and Methods Top


Between January 2000 and June 2007, the records of all patients with primary diagnosis of PE admitted to the medical ICU in our institute were reviewed. The diagnosis of PE was confirmed by a high-probability ventilation/perfusion (V/Q) scan [7] or spiral computed tomography (CT) scan showing one or more filling defects or obstruction in the pulmonary artery or its branches. [8] Massive PE was defined as the presence of hypotension or shock whereas submassive PE was defined as stable hemodynamics in the presence of echocardiographic right ventricular(RV) dysfunction based on RV dilatation (end diastolic diameter > 30mm) or hypokinesia or abnormal movement of the interventricular septum with or without tricuspid regurgitation. [9] A data entry form was designed to collect demographic, clinical and radiological data on admission to the ICU. This included age, gender, clinical presentation, risk factors (obesity defined as body mass index > 30), immobility, recent surgery within 1 week, oral contraceptive pills and antiphospholipid syndrome), comorbid medical conditions, namely congestive cardiac failure, chronic obstructive pulmonary disease (COPD), cancer, chronic kidney diseases, connective tissue diseases and cerebrovascular diseases. Additionally, vital signs, electrocardiographic, chest X-ray findings (normal, pleural effusion, local oligemia, cardiomegaly, atelectasis, raised hemidiaphragm, prominent pulmonary artery and wedge-shaped opacity) and arterial blood gas values were recorded. Chest X-rays were read by a radiologist who was blinded to the patient's diagnosis and outcome. Therapeutic agents given, either unfractionated heparin alone or thrombolytic agent (tissue plasminogen activator, t-PA), were noted. The number of patients who died in the ICU and in the hospital was recorded as the primary clinical outcome and patients were grouped accordingly into survivors and nonsurvivors. The eight nonsurvivors were compared with 16 randomly selected survivors from 48 survivors in relation to the above-mentioned clinical variables as an unmatched case control study design.

Statistical analysis

The data were entered in Microsoft excel and analyzed using the statistical package for social sciences (SPSS Inc., 233 S. Wacker Drive, 11 th Floor, Chicago, IL 60606-6307) for personal computer version 16 software. Data was expressed in text and tables as mean ± standard deviation and proportions for continuous and categorical variables. Bivariate analysis was performed using Student's t -test for two independent groups of the continuous variables and Fisher's exact test to observe significant association of the categorical variables in relation to the outcome. Difference was considered significant at P < 0.05.


   Results Top


Fifty-six patients (43% females) with PE were admitted to the ICU during the study period. Their mean age was 40.6 ± 10.6 years. Seven (12.5%) patients were diagnosed as massive PE and 15 (26.8%) as submassive according to the above-mentioned criteria. The remaining patients were admitted due to severe hypoxemia (mean PaO 2 at room air = 54.89 ± 6.85 mm Hg). The diagnosis of PE was made by spiral CT in 44 patients and by V/Q scan in eight. Four patients in whom the clinical suspicion of PE was high, but were unstable to undergo any confirmative imaging, were diagnosed based on a positive duplex study of the legs showing proximal deep vein thrombosis (DVT) along with echocardiographic evidence of RV dilation and dysfunction. The clinical presentation, risk factors and comorbid conditions of the study group are shown in [Table 1]. Dyspnea, cough and chest pain were the main presenting symptoms in 39 (69.6%), 35 (62.5%) and 33 (58.9%) patients, respectively. Recent surgery followed by obesity were the most common risk factors in our study group (55.4 and28.6%, respectively). More than half of the patients had concomitant cardiorespiratory conditions. Chest X-ray was normal in 41 (73.2%) patients. However, the most frequent abnormality noted was cardiomegaly in 13 (23%) cases followed by lung oligemia in eight (14%) [Table 2]. Treatment was started before definitive diagnosis in the majority (87.5%) of the cases. Only four patients out of the seven who had massive PE received thrombolysis with t-PA because the remaining three patients had surgery within 72 h of the development of PE. All seven patients with massive PE required ionotropic support and were mechanically ventilated for a mean duration of 45.5 ± 12.4 h. One patient with massive PE developed fatal gastrointestinal bleeding post thrombolysis. Three other patients died within 48 h of admission to the ICU and four patients died after 72 h. Five of the patients who died had submassive and two had massive PE resulting in an overall mortality rate of 14%. Only one among those who died received thrombolytic therapy, which was given twice due to the lack of clinical improvement. Compared with survivors, nonsurvivors were found to be significantly older (56.4 ± 10.3) years vs. (46.2 ± 7.2) years, respectively ( P = 0.01)) [Table 3]. However, there was no gender difference between the two groups. A greater number of nonsurvivors had preexisting connective tissue or cerebrovascular diseases at the time of diagnosis of PE. On the other hand, no significant difference was found in the frequency of cardiovascular, respiratory or renal conditions. All of the patients who died had recent surgery and most of them (75%) were immobile. Comparing vital signs on admission to the ICU, nonsurvivors were more tachypneic and tachycardic and their diastolic blood pressure was lower than the survivors' [Table 3]. Arterial blood gas analyses in nonsurvivors showed significantly lower PaO 2 and O 2 saturation; however, there was no difference in PaCO 2 measurements.


   Discussion Top


The outcome of patients with PE is quite variable depending primarily on the hemodynamic status and the embolus size. However, other factors have been found in many studies to be useful as prognostic indicators. In this study, we described the outcome and the factors associated with poor prognosis of patients with PE admitted to the medical ICU of a teaching hospital in Riyadh, Saudi Arabia, as no study has addressed this issue in Middle Eastern hospitals. The overall in-hospital mortality rate for the 56 patients studied in our center was 14%. The MAPPET registry reported an overall mortality rate of 1001 patients with PE to be 29% (14% in the presence of hypotension, 25% in cases of cardiogenic shock and 65% post cardiac arrest). [2] Most of the patients who died in our ICU had submassive PE and were normotensive on admission. Their sudden collapse may indicate loss of the initial cardiovascular compensatory mechanisms, mainly reflex tachycardia and systemic arterial vasoconstriction. [10] Moreover, it has been reported that 10% of the initially diagnosed submassive PE develop shock after admission with 50% mortality. [11] Early initiation of anticoagulation based on high clinical suspicion is one of the known factors contributing to a favorable outcome in such patients. [12] Older studies have shown that the rate of DVT among general surgical patients who did not receive DVT prophylaxis ranges between 15 and 30% and subsequent fatal PE between 0.2 and 0.9% [13],[14] and this can further be affected by the type and duration of surgery and the type of anesthesia used. [15],[16],[17] Population-based studies estimated the risk of thrombosis to be increased two-folds in obese individuals.[18],[19] Chronic lung diseases and cardiovascular diseases were the main comorbid conditions present before the diagnosis of PE in our patients. Earlier studies have identified heart failure and COPD to be the major risk factors for venous thrombo-embolism in hospitalized medical patients. [5],[20],[21] Aujesty and Obrosky, in their prognostic model, found these conditions to be independently associated with higher 30-day mortality indicating worse prognosis. [22]

When clinical characteristics of nonsurvivors were compared with those of survivors, older age and coexistent connective tissue and cerebrovascular diseases as well as immobility were found to be more common in the nonsurvivor group. Older age is well known to correlate poorly with survival post PE. [5],[22],[23] Prolonged immobilization was found to be an independent factor for increased mortality among 533 patients with PE hospitalized in Japan. [24] Nonsurvivors were significantly more tachypneic, tachycardic and hypoxemic on admission than survivors. This is in accordance with previous reports that utilized the above clinical parameters among others to stratify patients with PE into five classes with increasing mortality. [22],[25],[26] Although systolic blood pressure (BP) was not different among the two groups, diastolic BP on admission was significantly lower in nonsurvivors. We think this could be related to loss of the initial compensatory vasoconstriction signaling impending hypotension and shock. However, this needs to be confirmed in larger studies.

There are some limitations to this study that need to be addressed, which include the small number of patients enrolled and the retrospective nature of the study in addition to the comparison of nonsurvivors with survivors as an unmatched control group.

Cardiac biomarkers, namely Troponin and Brain natriuretic peptide, levels were not included in the comparison between survivors and nonsurvivors because they were not available for all patients.

In summary, this is the first description from a Middle Eastern country of the outcome, risk factors and clinical characteristics of patients with PE admitted to the ICU. The mortality rate in this study is comparable to previously published reports from other parts of the world, despite the fact that most of our patients had significant premorbid conditions. Older age, cerebrovascular and connective tissue diseases as well as immobility were factors associated with poor outcome.

 
   References Top

1.Naess IA, Christiansen SC, Romundstad P, Cannegieter SC, Rosendaal FR, Hammerstrom J. Incidence and mortality of venous thrombosis: A population-based study. J Thromb Haemost 2007;5:692-9.  Back to cited text no. 1    
2.Kasper W, Konstantinides S, Geibel A, Olschewski M, Heinrich F, Grosser KD, et al . Management strategies and determinants of outcome in acute major pulmonary embolism: Results of a multicenter registry. J Am Coll Cardiol 1997;30:1165-71.  Back to cited text no. 2  [PUBMED]  [FULLTEXT]
3.Konstantinides S, Geibel A, Olschewski M, Heinrich F, Grosser K, Rauber K, et al . Association between thrombolytic treatment and the prognosis of hemodynamically stable patients with major pulmonary embolism: Results of a multicenter registry. Circulation 1997;96:882-8.  Back to cited text no. 3  [PUBMED]  [FULLTEXT]
4.Kozak LJ, Owings MF, Hall MJ. National Hospital Discharge Survey: 2002 annual summary with detailed diagnosis and procedure data. Vital Health Stat 2005;158:1-199.  Back to cited text no. 4    
5.Goldhaber SZ, Visani L, De Rosa M. Acute pulmonary embolism: Clinical outcomes in the International Cooperative Pulmonary Embolism Registry (ICOPER). Lancet 1999;353:1386-9.  Back to cited text no. 5  [PUBMED]  [FULLTEXT]
6.Douketis JD. Prognosis in pulmonary embolism. Curr Opin Pulm Med 2001;7:354-9.  Back to cited text no. 6  [PUBMED]  [FULLTEXT]
7.Stein PD, Terrin ML, Gottschalk A, Alavi A, Henry JW. Value of ventilation/perfusion scans versus perfusion scans alone in acute pulmonary embolism. Am J Cardiol 1992;69:1239-41.  Back to cited text no. 7  [PUBMED]  
8.Chin P, Hurrell M, McGregor D, Beckert L. The role of CT pulmonary angiography in patients with suspected pulmonary embolism admitted to general medicine. N Z Med J 2006;119:U2052.  Back to cited text no. 8  [PUBMED]  
9.Goldhaber SZ. Echocardiography in the management of pulmonary embolism. Ann Intern Med 2002;136:691-700.  Back to cited text no. 9  [PUBMED]  [FULLTEXT]
10.Goldhaber SZ. Assessing the prognosis of acute pulmonary embolism: Tricks of the trade. Chest 2008;133:334-6.  Back to cited text no. 10  [PUBMED]  [FULLTEXT]
11.Grifoni S, Olivotto I, Cecchini P, Pieralli F, Camaiti A, Santoro G, et al . Short-term clinical outcome of patients with acute pulmonary embolism, normal blood pressure and echocardiographic right ventricular dysfunction. Circulation 2000;101:2817-22.  Back to cited text no. 11  [PUBMED]  [FULLTEXT]
12.Wood KE. Major pulmonary embolism: Review of a pathophysiologic approach to the golden hour of hemodynamically significant pulmonary embolism. Chest 2002;121:877-905.  Back to cited text no. 12  [PUBMED]  [FULLTEXT]
13.Clagett GP, Reisch JS. Prevention of venous thromboembolism in general surgical patients: Results of meta-analysis. Ann Surg 1988;208:227-40.  Back to cited text no. 13  [PUBMED]  [FULLTEXT]
14.Pezzuoli G, Neri Serneri GG, Settembrini P, Coggi G, Olivari N, Buzzetti G, et al . Prophylaxis of fatal pulmonary embolism in general surgery using low-molecular weight heparin Cy 216: A multicentre, double-blind, randomized, controlled, clinical trial versus placebo (STEP). STEP-Study Group. Int Surg 1989;74:205-10.  Back to cited text no. 14    
15.Ageno W. Applying risk assessment models in general surgery: Overview of our clinical experience. Blood Coagul Fibrinolysis 1999;10:S71-8.  Back to cited text no. 15  [PUBMED]  
16.Hendolin H, Mattila MA, Poikolainen E. The effect of lumbar epidural analgesia on the development of deep vein thrombosis of the legs after open prostatectomy. Acta Chir Scand 1981;147:425-9.  Back to cited text no. 16  [PUBMED]  
17.Prins MH, Hirsh J. A comparison of general anesthesia and regional anesthesia as a risk factor for deep vein thrombosis following hip surgery: A critical review. Thromb Haemost 1990;64:497-500.  Back to cited text no. 17  [PUBMED]  
18.Abdollahi M, Cushman M, Rosendaal FR. Obesity: Risk of venous thrombosis and the interaction with coagulation factor levels and oral contraceptive use. Thromb Haemost 2003;89:493-8.  Back to cited text no. 18  [PUBMED]  [FULLTEXT]
19.Pomp ER, le Cessie S, Rosendaal FR, Doggen CJ. Risk of venous thrombosis: Obesity and its joint effect with oral contraceptive use and prothrombotic mutations. Br J Haematol 2007;139:289-96.  Back to cited text no. 19  [PUBMED]  [FULLTEXT]
20.Cohen AT. Venous thromboembolic disease management of the nonsurgical moderate- and high-risk patient. Semin Hematol 2000;37:19-22.  Back to cited text no. 20  [PUBMED]  
21.Howell MD, Geraci JM, Knowlton AA. Congestive heart failure and outpatient risk of venous thromboembolism: A retrospective, case-control study. J Clin Epidemiol 2001;54:810-6.  Back to cited text no. 21  [PUBMED]  [FULLTEXT]
22.Aujesky D, Obrosky DS, Stone RA, Auble TE, Perrier A, Cornuz J, et al . Derivation and validation of a prognostic model for pulmonary embolism. Am J Respir Crit Care Med 2005;172:1041-6.  Back to cited text no. 22  [PUBMED]  [FULLTEXT]
23.Jimenez D, Diaz G, Molina J, Marti D, Del Rey J, Garcia-Rull S, et al . Troponin I and risk stratification of patients with acute nonmassive pulmonary embolism. Eur Respir J 2008;31:847-53.  Back to cited text no. 23    
24.Miyahara Y, Ikeda S, Kono S. Incidence and Prognosis of Pulmonary Embolism in Japan. Jpn J Intensive Care Med 2004;28:147-50.  Back to cited text no. 24    
25.Aujesky D, Roy PM, Le Manach CP, Verschuren F, Meyer G, Obrosky DS, et al . Validation of a model to predict adverse outcomes in patients with pulmonary embolism. Eur Heart J 2006;27:476-81.  Back to cited text no. 25  [PUBMED]  [FULLTEXT]
26.Roy PM, Meyer G, Vielle B, Le Gall C, Verschuren F, Carpentier F, et al . Appropriateness of diagnostic management and outcomes of suspected pulmonary embolism. Ann Intern Med 2006;144:157-64.  Back to cited text no. 26  [PUBMED]  [FULLTEXT]



 
 
    Tables

  [Table 1], [Table 2], [Table 3]

This article has been cited by
1 Delayed anticoagulation is associated with poor outcomes in high-risk acute pulmonary embolism
Sarah Soh,Jeong Min Kim,Jin Ha Park,Shin Ok Koh,Sungwon Na
Journal of Critical Care. 2015;
[Pubmed] | [DOI]
2 Occult pulmonary embolism in intensive care unit patients undergoing chest computed tomography scan: Incidence and effect on outcomes
Arnoult, E. and Wiramus, S. and Textoris, J. and Craighero, F. and Ragonnet, B. and Hammad, E. and Chaumoître, K. and Martin, C. and Leone, M.
Journal of Cardiothoracic and Vascular Anesthesia. 2013; 27(3): 474-478
[Pubmed]
3 Occult Pulmonary Embolism in Intensive Care Unit Patients Undergoing Chest Computed Tomography Scan: Incidence and Effect on Outcomes
Elodie Arnoult,Sandrine Wiramus,Julien Textoris,Fabien Craighero,Benoit Ragonnet,Emmanuelle Hammad,Kathia Chaumoître,Claude Martin,Marc Leone
Journal of Cardiothoracic and Vascular Anesthesia. 2013; 27(3): 474
[Pubmed] | [DOI]
4 Pulmonary embolism in mechanically ventilated patients requiring computed tomography
Clémence Minet,Maxime Lugosi,Pierre Yves Savoye,Caroline Menez,Stéphane Ruckly,Agnès Bonadona,Carole Schwebel,Rebecca Hamidfar-Roy,Perrine Dumanoir,Claire Ara-Somohano,Gilbert R. Ferretti,Jean-François Timsit
Critical Care Medicine. 2012; 40(12): 3202
[Pubmed] | [DOI]
5 Pulmonary embolism in mechanically ventilated patients requiring computed tomography: Prevalence, risk factors, and outcome
Minet, C. and Lugosi, M. and Savoye, P.Y. and Menez, C. and Ruckly, S. and Bonadona, A. and Schwebel, C. and Hamidfar-Roy, R. and Dumanoir, P. and Ara-Somohano, C. and Ferretti, G.R. and Timsit, J.-F.
Critical Care Medicine. 2012; 40(12): 3202-3208
[Pubmed]
6 Pulmonary embolism in intensive care unit " literature review"
Bahloul, M. and Chaari, A. and Ben Algia, N. and Bouaziz, M.
Trends in Anaesthesia and Critical Care. 2012; 2(1): 25-29
[Pubmed]
7 Risk Factors Associated with Delayed Diagnosis of Acute Pulmonary Embolism
Sean B. Smith, Jeffrey B. Geske, Timothy I. Morgenthaler
Journal of Emergency Medicine. 2011;
[VIEW] | [DOI]
8 Pulmonary embolism in intensive care unit “literature review”
Mabrouk Bahloul, Anis Chaari, Najla Ben Algia, Mounir Bouaziz
Trends in Anaesthesia and Critical Care. 2011;
[VIEW] | [DOI]
9 Effecting factors on survival in patients taking thrombolytic treatment due to massive pulmonary embolism | [Masif pulmoner emboli nedeniyle trombolitik tedavi uygulanan hastalarda yaşam süresi üzerine etki eden faktörler]
Hatipoǧlu, O.N., Perinçek, G., Çakir Edis, E., Tabakoǧlu, E., Altiay, G.
Tuberkuloz ve Toraks. 2010; 58(3): 268-277
[Pubmed]
10 Pulmonary embolism in intensive care unit: Predictive factors, clinical manifestations and outcome
Bahloul, M., Chaari, A., Kallel, H., Abid, L., Hamida, C.B., Dammak, H., Rekik, N., (...), Bouaziz, M.
Annals of Thoracic Medicine. 2010; 5(2): 97-103
[Pubmed]
11 Pulmonary embolism in intensive care unit: Predictive factors, clinical manifestations and outcome
Bahloul, M. and Chaari, A. and Kallel, H. and Abid, L. and Hamida, C.B. and Dammak, H. and Rekik, N. and Mnif, J. and Chelly, H. and Bouaziz, M.
Annals of Thoracic Medicine. 2010; 5(2): 97-103
[Pubmed]



 

Top
Print this article  Email this article
 
  Search
 
   Next article
   Previous article 
   Table of Contents
  
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Article in PDF (693 KB)
    Citation Manager
    Access Statistics
    Reader Comments
    Email Alert *
    Add to My List *
* Registration required (free)  


    Abstract
    Materials and Me...
    Results
    Discussion
    References
    Article Tables

 Article Access Statistics
    Viewed7567    
    Printed207    
    Emailed1    
    PDF Downloaded743    
    Comments [Add]    
    Cited by others 11    

Recommend this journal