Management of Massive Pulmonary Embolism in the Intensive Care Unit

Abstract

Major pulmonary embolism (PE), defined by the presence of shock, is a leading cause of mortality. The aim of this review is to summarize the latest advances and recommendations regarding the management of severe PE. The stratification of individual early mortality risk allows the optimization of the diagnostic and therapeutic approach for each patient. The symptomatic management is essentially focused on the hemodynamic support. Unfractioned heparin is indicated for hemodynamically unstable patients. In these high-risk patients, systemic thrombolysis decreases mortality and the risk of PE recurrence. In high-intermediate-risk patients, systemic thrombolysis given at current dosage decreases the risk of secondary hemodynamic decompensation but without effect on the overall mortality. Accordingly, thrombolytic therapy should be given to high-intermediate-risk patients in case of secondary hemodynamic worsening. Surgical embolectomy is still recommended in patients with absolute contraindication to thrombolysis and in case of thrombolysis failure. The place of extracorporeal assistance and percutaneous revascularization treatment in the therapeutic algorithm need to be better defined. Consequently, their indication should be decided in an expert center after a multidisciplinary discussion involving lung physician, cardiologist, interventional radiologist, and cardiac surgeon.