35. Pulmonary Embolism Masterclass with Dr. Rich Channick
Oct 7, 2024
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Dr. Rich Channick, an intensivist at UCLA specializing in pulmonary vascular disease, shares his expert insights on managing pulmonary embolism. He discusses the intricacies of risk stratification and the importance of tailor-made treatment strategies. The conversation dives into advanced interventions like catheter-directed therapies and the role of Pulmonary Embolism Response Teams. With a focus on clinical decision-making, the episode also highlights the latest advances in thrombolytic therapy and ongoing research in improving patient outcomes.
Timely initiation of anticoagulation within the first 24 hours of diagnosis is crucial for improving outcomes in pulmonary embolism patients.
Accurate risk stratification using biomarker analysis and scoring systems is vital for tailoring treatment plans in pulmonary embolism management.
Collaboration among multidisciplinary teams is essential for considering advanced interventions, such as catheter-directed therapies or ECMO, in complex PE cases.
Deep dives
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Importance of Anticoagulation in Pulmonary Embolism
Anticoagulation plays a crucial role in reducing the risk of recurrent pulmonary embolism (PE) and should be initiated within the first 24 hours of diagnosis. This time frame is critical as the clot is considered unstable during this period, and timely anticoagulation can prevent further complications. The discussion highlights the significance of efficient treatment strategies, indicating that patients who are appropriately anticoagulated are likely to have better outcomes. Emphasis is placed on the necessity of starting anticoagulation quickly to improve patient prognosis.
Risk Stratification in Pulmonary Embolism Management
Risk stratification is essential for managing patients with pulmonary embolism, particularly distinguishing between low, intermediate, and high-risk groups. Factors such as biomarkers and the right ventricle to left ventricle ratio play significant roles in determining the patient's stability and treatment pathway. The episode delves into various scoring systems and tools that help physicians identify the severity of the condition and tailor interventions accordingly. Accurate risk assessment not only guides immediate treatment decisions but also helps anticipate potential deteriorations in patients' conditions.
Interventions When Anticoagulation is Insufficient
The discussion explores various treatment options for patients whose conditions may not adequately respond to anticoagulation alone, focusing on re-evaluation for potential interventions like catheter-directed thrombolysis or thrombectomy. These alternatives become particularly relevant in cases where systemic thrombolysis poses bleeding risks due to the patient's profile. The importance of collaboration among teams—such as interventional radiologists, intensivists, and emergency physicians—is emphasized in managing these complex cases. This multidisciplinary approach aims to ensure that patients receive optimal, individualized care based on their specific clinical presentations.
The Role and Challenges of ECMO in Massive PE Cases
Extracorporeal Membrane Oxygenation (ECMO) presents a potential lifesaving intervention for patients experiencing massive pulmonary embolism with hemodynamic instability. The physiological benefits of ECMO include unloading the right ventricle and mechanically supporting circulation, allowing for time to consider further interventions. While ECMO can provide critical stabilization, the discussion highlights the necessity for thorough patient evaluation to determine the most appropriate course of action. Debates continue regarding the timing and integration of ECMO with thrombolytic therapy, reflecting the need for individualized decision-making in acute care settings.
On this week's release, Cyrus and Nick revisit one of their favorite topics: Pulmonary Embolism! In this episode - a follow up to our two-parter from season 1 - we sit down with Dr. Rick Channick of UCLA to talk about his approach to PE management with a focus on catheter directed therapies & PE response teams. This episode is packed full of expert insights and practical clinical pearls. Give it a listen and let us know what you think!
Risk Stratification Methodologies
What is the landscape of risk stratification in Pulmonary Embolism (PE)?
Broadly, what interventions does each risk category group warrant?
Rule of Thumb: The greater the risk to the patient, the more likely aggressive interventions will be considered.
Most patients with PE are low risk:
Typically treated with systemic anticoagulation
Excellent prognosis
High risk PE patients typically have hemodynamic involvement and can present in shock requiring emergent management :
No contraindications + shock due to PE systemic thrombolysis
Absolute contraindications:
Prior history of ICH
Known cerebrovascular lesion
Known malignant intracranial neoplasm
Non-acute ischemic stroke, within the last 3 months
Suspect aortic dissection
Intermediate risk patients:
Management options exist and are tailored to each specific patient.
Most, but not all, patients with PE deemed to be at intermediate risk will do well with systemic anticoagulation.
Some patients are good candidates for catheter directed therapies such as thrombectomy or thrombolysis.
Who? We don’t really know with a high degree of certainty. Considerations should be made for those with numerous risk factors for poor PE-related outcomes OR those with significant cardiopulmonary reserve / excellent functional status who theoretically could benefit from more brisk reversal of their acute pulmonary hypertension.
