Salvage intraosseous thrombolysis and extracorporeal membrane oxygenation for massive pulmonary embolism

Abstract

Intraosseous access is an alternative route of pharmacotherapy during cardiopulmonary resuscitation. Extracorporeal membrane oxygenation (ECMO) provides cardiac and respiratory support when conventional therapies fail. This case reports the use of intraosseous thrombolysis and ECMO in a patient with acute massive pulmonary embolism (PE). A 34-year-old female presented to the emergency department with sudden onset severe shortness of breath. Due to difficulty establishing intravenous access, an intraosseous needle was inserted into the left tibia. Echocardiography identified severe right ventricular dilatation with global systolic impairment and failure, indicative of PE. Due to the patient's hemodynamic compromise a recombinant tissue plasminogen activator (Alteplase) bolus was administered through the intraosseous route. After transfer to the intensive care unit, venous-arterial ECMO was initiated as further therapy. The patient recovered and was discharged 36 days after admission. This is the first report of combination intraosseous thrombolysis and ECMO as salvage therapy for massive PE.

Extracorporeal membrane oxygenation (ECMO) for critically ill adults in the emergency department: history, current applications, and future directions

“…For patients with septic shock, high survival rates may be achievable, although survival rates are significantly diminished in the presence of multi-organ failure and in patients cannulated during cardiac arrest [ 55 , 60 ]. ECMO has shown promising results as a method of supporting hemodynamics in patients with cardiogenic shock due to acute myocardial infarction [ 61 ], massive pulmonary embolism [ 62 ] or myocarditis [ 63 ]. ECMO may be preferable to aortic balloon pumps as it can provide more robust biventricular support by increasing right ventricular drainage in addition to supporting gas exchange, and it can be employed quickly at the bedside.…”

Intraosseous infusion of drugs and fluids in critical patients: a systematic review

“…Esto supone un gran avance a la hora de tratar a pacientes a los que no se les puede canalizar un acceso venoso periférico, ya que la cateterización venosa central es una contraindicación relativa en pacientes a los que se les va a administrar una terapia fibrinólitica 23 . En el caso clínico descrito por Northey et al 34 presentan el uso de trombólisis intraósea en una paciente conectada a la membrana de oxigenación extracorpórea (ECMO) con embolismo pulmonar masivo agudo. El riesgo de hemorragia local y síndrome compartimental es mayor con el AIO de terapia trombolítica 32 , pero este efecto adverso no se observó.…”

A rare complication of extracorporeal membrane oxygenation and thrombolytic treatment in a patient with massive pulmonary embolism

“…In the literature, we could not find another case report with intraperitoneal bleeding after systemic fibrinolytic and ECMO treatment and prolonged CPR. [ 3 ]…”

“…[ 1 ] In patients undergoing ECMO and systemic fibrinolysis, a complication such as intraperitoneal bleeding is rarely reported. [ 3 ]…”