Mittal Abhinav, Mittal Anne P, Rojas Edward, Al-Jaroushi Hatim
Pulmonary, Critical Care & Sleep Medicine, West Virginia University, Morgantown, USA.
Neurocritical Care, West Virginia University, Morgantown, USA.
Cureus. 2020 May 21;12(5):e8218. doi: 10.7759/cureus.8218.
Acute massive pulmonary embolism (PE) has a high mortality if left untreated. The mainstay of treatment is systemic thrombolysis which has some absolute contraindications like intracranial hemorrhage (ICH). Inhaled nitric oxide (iNO) is a selective pulmonary vasodilator that decreases pulmonary artery pressure (PAP) and allows the right ventricle of the heart to pump against less resistance. We present a case of iNO use to improve hemodynamics in a patient with a recent ICH. We believe this to be the first such case reported. A 70-year-old female with a history of PE on Eliquis initially presented for weakness and was found to have right-sided ICH. She was discharged with instructions to hold Eliquis given ICH but was readmitted eight days later in florid cardiogenic shock requiring vasopressors and hypoxic respiratory failure refractory to intubation. CT showed bilateral PE with evidence of right heart strain and IV heparin was started. Due to her history of a recent ICH, she had an absolute contraindication prohibiting the use of systemic tissue plasminogen activator (tPA). Interventional radiology (IR) consult determined that the patient was not a candidate for catheter-directed tPA due to the recent ICH, mechanical ventilation, and hemodynamic instability based on pressor requirement. Vascular surgery and extracorporeal membrane oxygenation (ECMO) consults deemed the patient not operable. The patient was then started on iNO with immediate improvement in her blood pressure. Once vitally stable, IR consult performed pulmonary angiogram and completed a thrombectomy. The patient was eventually extubated and she restarted her Eliquis. She continues to do well 16 months after discharge. In patients with massive PE with contraindications to systemic thrombolytics, providers are left with very few therapeutic interventions. A handful of case reports show that iNO improves systemic hemodynamics in postoperative patients with massive PE. This case highlights the potential for iNO to be a potential adjuvant in patients with absolute contraindications to systemic thrombolysis.
急性大面积肺栓塞（PE）若不治疗，死亡率很高。治疗的主要方法是全身溶栓，但存在一些绝对禁忌证，如颅内出血（ICH）。吸入一氧化氮（iNO）是一种选择性肺血管扩张剂，可降低肺动脉压（PAP），使心脏右心室能以较小阻力泵血。我们报告一例在近期发生ICH的患者中使用iNO改善血流动力学的病例。我们认为这是首例此类报道的病例。一名70岁女性，有服用阿哌沙班治疗PE的病史，最初因身体虚弱就诊，被发现有右侧ICH。因ICH，她出院时被告知停用阿哌沙班，但8天后因严重的心源性休克再次入院，需要血管加压药，且插管后出现难治性低氧性呼吸衰竭。CT显示双侧PE并有右心劳损迹象，遂开始静脉注射肝素。由于她近期有ICH病史，存在绝对禁忌证，禁止使用全身组织型纤溶酶原激活剂（tPA）。介入放射科（IR）会诊确定，鉴于近期的ICH、机械通气以及基于血管加压药需求的血流动力学不稳定，该患者不适合进行导管定向tPA治疗。血管外科和体外膜肺氧合（ECMO）会诊认为该患者无法进行手术。然后该患者开始使用iNO，血压立即得到改善。生命体征一旦稳定，IR会诊进行了肺血管造影并完成了血栓切除术。患者最终拔管，并重新开始服用阿哌沙班。出院16个月后她情况一直良好。对于有全身溶栓禁忌证的大面积PE患者，医生的治疗干预手段非常有限。一些病例报告显示，iNO可改善大面积PE术后患者的全身血流动力学。本病例突出了iNO在有全身溶栓绝对禁忌证的患者中作为潜在辅助治疗手段的可能性。
