Low-Dose Thrombolysis Effective in Moderate Pulmonary Embolism
Clinical question: Can low-dose tissue plasminogen activator (tPA) help reduce pulmonary artery pressure in those with moderate pulmonary embolism (PE)?
Background: Studies have shown full-dose thrombolysis can effectively decrease pulmonary artery pressure in patients with massive PE. However, there are limited data regarding low-dose or “safe dose” thrombolytic therapy and its effect on pulmonary artery pressure.
Study design: Prospective, controlled, randomized study.
Setting: Single center.
Synopsis: The Moderate Pulmonary Embolism Treated with Thrombolysis (MOPETT) study enrolled patients with moderate PE, defined as signs and symptoms of PE plus computed tomographic pulmonary angiographic involvement of > 70% involvement of thrombus in ≥2 lobar or left/right main pulmonary arteries or high probability ventilation/perfusion scan (mismatch in ≥2 lobes). Patients in the thrombolysis group (n=61) were given low-dose tPA (100 mg tPA) and anticoagulation vs. the control group (n=60), which received only anticoagulation.
The study ran for 22 months, and the primary end points were pulmonary hypertension and recurrent PE. After analysis, low-dose thrombolysis was shown to significantly decrease pulmonary artery pressure and occurrence of recurrent PE compared to the control group.
This study demonstrates that, while the decision to use thrombolytics should always be made cautiously, hospitalists can consider low-dose thrombolysis in patients with moderate PE.
Bottom line: Low-dose thrombolysis, in addition to anticoagulation, in patients with moderate PE decreases pulmonary hypertension and recurrent PE.
Citation: Sharifi M, Bay C, Skrocki L, Rahimi F, Mehdipour M. Moderate pulmonary embolism treated with thrombolysis (from the “MOPETT” trial). Am J Cardiol. 2013;111(2):273-277.
High Mortality in Surgical Patients Requiring CPR
Clinical question: What are the incidence, characteristics, and 30-day-outcomes of CPR in surgical patients?
Background: Most studies of CPR are based on the medical population, and little is known about the utilization, risk factors, and outcomes of CPR in surgical patients.
Study design: Retrospective cohort study.
Setting: Two hundred fifty U.S. hospitals in the American College of Surgeons’ National Surgical Quality Improvement Program.
Synopsis: A total of 1.3 million surgical cases were studied in the data set. The overall incidence was 1 event per 203 cases. Most patients (77.6%) experienced a complication and did so on or before the day of CPR in three-fourths of cases. The incidence of CPR was the highest for cardiac surgery patients. Patients who received CPR had a mortality rate of 71.6%. Mortality rates of CPR patients increased with more comorbidities.
Additionally, older age and an American Society of Anesthesiologists (ASA) class of 5 was associated with higher mortality.
Limitations of this study included coding flaws in data collection, lack of capture of resuscitation-related injuries, and failure to account for changes in DNR orders.
Hospitalists should be mindful of risk factors contributing to CPR in surgical patients when performing perioperative evaluations.
Bottom line: Surgical patients who experience CPR have a high mortality rate, but many of these patients have pre-arrest complications that can be preventable.
Citation: Kazaure HS, Roman SA, Rosenthal RA, Sosa, JA. Cardiac arrest among surgical patients. JAMA Surg. 2013;148(1):14-21.
Emergency Department Visits are Frequent Post-Discharge
Clinical question: What role do ED visits contribute to the overall use of acute-care services within 30 days of hospital discharge?