Assuntos
Embolia Pulmonar/tratamento farmacológico , Terapia Trombolítica , Fibrinolíticos/química , Fibrinolíticos/farmacocinética , Fibrinolíticos/farmacologia , Fibrinolíticos/uso terapêutico , Ventrículos do Coração/fisiopatologia , Heparina/química , Heparina/farmacocinética , Heparina/farmacologia , Heparina/uso terapêutico , Humanos , Infarto do Miocárdio/etiologia , Embolia Pulmonar/complicações , Embolia Pulmonar/diagnóstico , Estreptoquinase/química , Estreptoquinase/farmacocinética , Estreptoquinase/farmacologia , Estreptoquinase/uso terapêuticoRESUMO
A study was conducted in 14 patients with pericardial syndrome after pulmonary embolism. The role of right ventricular myocardial injury and noncardiogenic pulmonary edema in this syndrome is considered and its existence is established.
Assuntos
Pericardite/etiologia , Embolia Pulmonar/complicações , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Pericardite/diagnóstico , Pericardite/tratamento farmacológico , Embolia Pulmonar/diagnóstico , Embolia Pulmonar/tratamento farmacológico , SíndromeRESUMO
To test the efficacy of intrapleural fibrinolytic therapy in patients with loculated pleural effusions, we conducted an open, prospective, and multicenter trial among five hospitals in Mexico. We enrolled patients with hemothorax or empyema, clotted and/or loculated, that was not resolved through conventional pleural drainage with chest tube and antibiotics in patients with empyema. All patients received repeated doses of 250,000 IU of streptokinase through chest tube. Effectiveness criteria were before and after intrapleural streptokinase (IPSK) drainage, and poststreptokinase radiographic and respiratory function test improvement. Forty-eight patients were studied; there were 30 patients with empyemas, 14 with hemothorax, and 4 patients with malignant pleural effusions without lung trapping. Successful fibrinolysis was obtained in 44 patients, with complete resolution of the pleural collection and adequate radiologic and spirometric improvement. In three of four patients with multiloculated malignant hemothorax with high-yielding pleural drainage, IPSK allowed successful lysis of loci and an adequate pleurodesis was achieved. Only four patients required surgical treatment. The overall success rate in our series was 92%, similar to previous reports. The results in this first prospective and multicentric trial suggest that intrapleural fibrinolysis is an effective and safe adjunctive treatment in patients with heterogeneous pleural coagulated and loculated collections to restore the pulmonary function assessed by respiratory function tests and can obviate surgery in most cases.
Assuntos
Empiema Pleural/tratamento farmacológico , Hemotórax/tratamento farmacológico , Estreptoquinase/uso terapêutico , Terapia Trombolítica , Adolescente , Adulto , Idoso , Tubos Torácicos , Terapia Combinada , Drenagem , Empiema Pleural/diagnóstico por imagem , Feminino , Hemotórax/diagnóstico por imagem , Humanos , Pulmão/diagnóstico por imagem , Masculino , Pessoa de Meia-Idade , Derrame Pleural Maligno/diagnóstico por imagem , Derrame Pleural Maligno/tratamento farmacológico , Estudos Prospectivos , Estreptoquinase/administração & dosagem , Estreptoquinase/efeitos adversos , Terapia Trombolítica/efeitos adversos , Tomografia Computadorizada por Raios XRESUMO
The hemodynamic and cardiovascular responses to a massive pulmonary embolism are: severe pulmonary hypertension, right ventricular failure and cardiogenic shock. The irreversible state of the latest condition and mortality could be due to a secondary right ventricle myocardial infarction, an entity which was first described in 1949. We report a necropsy case with massive pulmonary embolism and as a relevant finding a recent right ventricular myocardial infarction without significant obstructive coronary lesions. The relevance of right ventricle myocardial infarction as a major risk factor for mortality, its clinical and hemodynamic profile as well as the ischemic phenomena, are analyzed. It is emphasized also the importance of an early lysis of thrombus to rescue myocardium and to preserve right ventricle viability. This could be the first case reported in Mexico, in which the relationship between massive pulmonary embolism and right ventricle myocardial infarction is demonstrated as a determinant factor for mortality.
Assuntos
Infarto do Miocárdio/etiologia , Embolia Pulmonar/complicações , Doença Aguda , Eletrocardiografia , Evolução Fatal , Ventrículos do Coração/patologia , Humanos , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/diagnóstico , Infarto do Miocárdio/patologia , Artéria Pulmonar/patologia , Embolia Pulmonar/diagnóstico , Embolia Pulmonar/patologiaRESUMO
To test the efficacy of thrombolytic therapy in massive pulmonary embolism, we conducted a prospective randomized controlled trial. Eight patients were randomized to receive either 1,500,000 IU of streptokinase in 1 hour through a peripheral vein followed by heparin or heparin alone. All patients had major risk factors for deep vein thrombosis (DVT) and were considered to have high clinical suspicion for pulmonary embolism (PE). At baseline all patients had a similar degree of systemic arterial hypotension, pulmonary arterial hypertension, and right ventricular dysfunction. The time of onset of cardiogenic shock in both groups was comparable (2.25 +/- 0.5 hours in the streptokinase group and 1.75 +/- 0.96 hours in the heparin group). The four patients who were randomized to streptokinase improved in the first hour after treatment, survived, and in 2 years of follow-up are without pulmonary arterial hypertension. All four patients treated with heparin alone died from 1 to 3 hours after arrival at the emergency room (p = 0.02). Post-thrombolytic therapy the diagnosis of PE was sustained in the streptokinase group by high probability V/Q lung scans and proven DVT. A necropsy study performed in three patients in the heparin group showed massive pulmonary embolism and right ventricular myocardial infarction, without significant coronary arterial obstruction. The results indicate that thrombolytic therapy reduces the mortality rate of massive acute pulmonary embolism.
RESUMO
We report the case of a 65 year old woman with no prior cardiac or pulmonary disease, who suffered pulmonary embolism (PE); diagnosis was made on the basis of the existence of risk factors, clinical, radiographic and electrocardiographic features, and a lung scan with perfusion defects and normal ventilation. PE was considered massive because the patient developed acute respiratory failure that required tracheal intubation and mechanical ventilation as well as obstructive shock, electrocardiographic and echocardiographic data of right ventricle overload, and pulmonary hypertension, with pulmonary artery pressure of 38 mmHg. She received an initial treatment with high doses (1,500,000 UI) and rapid infusion (1 hr) of intravenous streptokinase (SK) followed by heparin anticoagulation. Thereafter the hemodynamic disturbances improved and pulmonary artery pressure post-thrombolysis was 23 mmHg. In this report SK at high doses and rapid infusion showed effectiveness and security. We emphasize the usefulness of echocardiography as a diagnostic aid in patients with a previously healthy cardiopulmonary system, as well as the possible role of electrocardiogram as an early indicator of pulmonary reperfusion. This could be the first report of successful thrombolysis with high doses and rapid infusion of SK in massive PE.
Assuntos
Embolia Pulmonar/tratamento farmacológico , Estreptoquinase/administração & dosagem , Terapia Trombolítica/métodos , Doença Aguda , Idoso , Eletrocardiografia/efeitos dos fármacos , Feminino , Humanos , Infusões Intravenosas , Embolia Pulmonar/diagnóstico , Indução de RemissãoRESUMO
We report a prospective study of 50 patients with chronic pulmonary pathology of diverse etiology and various grades of abnormality in Pulmonary mechanics and blood gases. In all patients we performed pulmonary function test and hemodynamic study with a Dotter-Lucas catheter with and without unilateral occlusion of pulmonary artery, at rest and during exercise. Our objective was to define if one or more parameters of routine pulmonary function test could allow us to predict the condition of pulmonary circulation, and therefore identify those patients at risk of pulmonary hypertension in whom pneumonectomy could be contraindicated and in this way avoid cardiac catheterization. We did not find any correlation between the grade of abnormality in pulmonary mechanics and the severity of pulmonary hypertension. On the other hand, all patients with severe pulmonary hypertension, that precluded pneumonectomy, had severe hypoxemia (PaO2 less than 50 mmHg); patients with moderate hypoxemia (PaO2 50-57 mmHg) had pulmonary hypertension of diverse grade, that could preclude or not, pneumonectomy. We conclude that this group of patients need to be catheterized to evaluate the indication of pneumonectomy.
Assuntos
Hemodinâmica , Pneumonectomia , Testes de Função Respiratória , Adolescente , Adulto , Idoso , Cateterismo Cardíaco , Feminino , Humanos , Hipertensão Pulmonar/etiologia , Masculino , Pessoa de Meia-Idade , Oxigênio/sangue , Pneumonectomia/efeitos adversos , Estudos Prospectivos , Circulação Pulmonar , Fatores de RiscoRESUMO
We report our experience with five children with pulmonary embolism and infarction. Two with congenital heart disease, one with rheumatic cardiopathy and two with a previously healthy cardiopulmonary system. The risk factors, clinical behavior and ECG were similar to those in adults. In chest roentgenogram we found pulmonary infarction with cavitations in three patients because of a delayed diagnosis. All patients had hypoxemia and hypocapnia, and diagnosis was made on the basis of segmentary or larger defects in perfusion gammagraphy. In just one case we obtained V/Q gammagraphy and pulmonary angiography. In one case we confirmed the clinical diagnosis by autopsy. We conclude that it is very important to keep this diagnosis in mind in all children with respiratory failure.
Assuntos
Embolia Pulmonar/diagnóstico , Adolescente , Criança , Pré-Escolar , Feminino , Heparina/administração & dosagem , Humanos , Masculino , Embolia Pulmonar/tratamento farmacológico , RecidivaRESUMO
Forty patients with overt pulmonary edema secondary to ischemic heart disease were treated in the emergency room with iv ouabain and furosemide; 20 patients in Group A received sublingual nifedipine before undergoing early tracheal intubation and mechanical ventilation with 100% FiO2 during 15 min. and then 50% FiO2; 20 patients in Group B received iv aminophylline, rotating tourniquets and IPPB by mask with 60% FiO2. All patients in Group A were extubated after 66 +/- 10.8 min. in the emergency room; 7 in Group B improved but 13 had to undergo tracheal intubation and mechanical ventilation. Upon arrival at the ICCU all had a Swan-Ganz catheter installed and received comparable therapy for ischemic heart disease. Statistically significant differences in favor of patients in Group A as compared to the 7 improved in B were seen in heart rate, arrhythmias, diastolic blood pressure, mean and wedge pulmonary pressures, systemic resistances, arterial pH and PaO2; when compared to the 13 patients undergoing late tracheal intubation and mechanical ventilation, parameters were more or less similar but improvement appeared later and extubation took place after 1.94 +/- 1.24 days (P less than 0.05). Three patients in Group B died in the emergency room, 3 in Group A and 4 in B died in the ICCU (P less than 0.01). Early tracheal intubation and mechanical ventilation in patients with overt pulmonary edema secondary to ischemic heart disease produce better results due to early improvement in pulmonary and systemic hemodynamics and should be considered in all such patients arriving at the emergency room.
Assuntos
Doença das Coronárias/complicações , Intubação Intratraqueal , Edema Pulmonar/etiologia , Respiração Artificial , Adulto , Feminino , Hemodinâmica , Humanos , Respiração com Pressão Positiva Intermitente , Masculino , Pessoa de Meia-Idade , Edema Pulmonar/fisiopatologia , Edema Pulmonar/terapiaRESUMO
The radiologic appearance of atypical cardiogenic pulmonary edema (ACPE) is presented in 10 cases admitted from 1983 to 1985, with age ranges from 74 to 89, and with diagnosis of ischemic heart disease, with myocardial infarction in 50% of them. Clinically they had asthenia, adynamia and anorexia in 80%, cough and weight loss in 50%. All of them had tachycardia, pulmonary rales and 50% pericardial rub. ECG showed in 80% anterior subepicardial ischemia, 60% posteroinferior subepicardial ischemia, 60% bifascicular block, and 50% left anterior fascicular block. Chest films were interpreted at first as pulmonary fibrosis in 90% of the cases with superior lobe involvement in 50%. Heart enlargement was present in 50%. A chronic lung disease was disclosed on clinical and pulmonary physiological grounds. It is concluded that asthenia, adynamia and anorexia were atypical manifestations of heart failure in the elderly. Silent myocardial infarction was observed in half of our patients and it was complicated with pericardial involvement in 50%. Irregular distribution of fluids in pulmonary edema was attributed to anatomic changes in elder lung. These atypical behaviour of pulmonary edema, has been misinterpreted on radiologic basis with pulmonary infection, tumours, metastasis or fibrosis. Those radiologic changes disappeared or improved in 72 hrs. with treatment of left ventricular failure.
Assuntos
Doença das Coronárias/complicações , Edema Pulmonar/diagnóstico por imagem , Idoso , Idoso de 80 Anos ou mais , Doença das Coronárias/diagnóstico por imagem , Doença das Coronárias/fisiopatologia , Eletrocardiografia , Humanos , Edema Pulmonar/etiologia , RadiografiaRESUMO
The classic electrocardiographic abnormalities observed in massive or submassive thromboembolism in the absence of preexistent cardiac or pulmonary disease are: S1Q3T3 pattern, right axis deviation, "pulmonary" P wave, ST segment depression or elevation, subepicardic ischemia and transient right bundle branch block. Left axis deviation due to pulmonary embolism was first described in 1949; this same finding and the presence of low voltage of the frontal plane owed to pulmonary embolism has been reported occasionally in the last decades, but it has had little diffusion. We report on a patient with no prior cardiac or pulmonary disease who suffered massive pulmonary thromboembolism. Electrocardiographically left axis deviation and low voltage of the horizontal plane attributed to pulmonary thromboembolism was observed. The mechanisms that originate this electrocardiographic changes in pulmonary embolism are unknown. Since the electrocardiogram is aspecific method for the diagnosis of this disorder, and the presence of the mentioned changes originate a greater difficulty in the diagnosis; we consider is important to publish it.