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Right Ventricular-Protective Strategies in Pulmonary Embolism With Cardiopulmonary Failure: Prone Positioning and
Jorge Beauregard-Mora1, Orlando Ruben Perez-Nieto2, Carlos Mendiola-Villalobos1
1Intensive Care Unit, Hospital General San Juan del Rio, Queretaro, Mexico.
Objective:
We describe a reproducible bedside strategy to unload the right ventricle (RV) and improve oxygenation after systemic thrombolysis in intubated patients with pulmonary embolism (PE) and cardiopulmonary failure (category E1+R) in centers without extracorporeal membrane oxygenation.
Key Steps:
Confirm category E1+R PE and give weight-adjusted systemic thrombolysis. Use restrictive fluids and a diuretic to decongest the RV. Use vasopressors and minimal sedation to maintain arterial pressure and perfusion. Apply RV-protective ventilation: zero positive end-expiratory pressure, low tidal volume, controlled hyperventilation. Correct acidosis toward mild alkalemia with sodium bicarbonate. Add prone positioning as rescue for refractory hypoxemia.
Potential Pitfalls:
Potential pitfalls include post-thrombolysis bleeding, positive end-expiratory pressure-induced RV afterload, airway or line dislodgment during prone positioning, propofol-related hypotension, and overventilation despite embolic dead space.
Take-Home Message:
In category E1+R PE, this RV-protective strategy can support the patient through the perithrombolysis period of greatest severity in centers without extracorporeal membrane oxygenation.
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