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PULMONOLOGY
and sedation is resumed. Patient
remained hemodynamically
stable throughout her admission
in ICU and did not require
vasopressors. Four days after
reintubation the patient was
successfully extubated and
discharged to medical ward. She
returned home seven days after
ICU discharge.
Discussion
Pulmonary emboli are
responsible for 10% of all
deaths in hospital and
are a contributory factor
in an additional 10%. In
contrast, reports of Venous
Thromboembolism (VTE) in
patients with HIV infection are
sparse. VTE is considered to
be ‘provoked’ in the presence
of a temporary or reversible
risk factor. These factors
include surgery, trauma,
immobilisation, pregnancy,
and oral contraceptive use or
hormone replacement therapy
and can occur within the last six
weeks to three months before
diagnosis.
PE may also occur in the
absence of any known risk
factor. If there are no risk factors
then the VTE is considered
‘unprovoked’. VTE is a major
cause of maternal mortality.
With the risk highest in the
third trimester of pregnancy
and over the six weeks of the
postpartum period. It is up to 60
times higher three months after
delivery, compared with the risk
in non-pregnant women.
In most patients, PE is
suspected on the basis of
dyspnoea, chest pain, pre-
syncope or syncope, and/
or haemoptysis. Once clinical
judgment has raised the
suspicion of PE, the assessment
of clinical probability is to
perform through the well
validated Wells score.
Multi-detector
computed tomographic
(MDCT) angiography has become
the diagnostic tool of choice in
patients with suspected PE.
Magnetic resonance
angiography (MRA) has been
evaluated as well as diagnostic
The Specialist Forum | Vol. 17 No. 4
method in suspected PE,
but it yields low sensitivity.
Echocardiography can be used
to assess right ventricular
function in patient with acute
PE, however, there is no
individual echocardiographic
parameter that provides fast
and reliable information on RV
size or function.
Echo has a negative predictive
value of 40-50%, so a negative
result cannot exclude PE.
Right ventricular dysfunction
in patient with PE has been
associated with adverse
outcome. RV dysfunction
indicates that caution is
required with intravenous fluids
expansion as it may worsen
the RV function by causing
mechanical overstretch, or
by reflex mechanisms that
depress contractility. A modest
fluid challenge (500 ml) may
help to increase cardiac
index in patients with PE and
hypotension.
Treatment
Vasopressors may be used to
support the blood pressure (BP)
when it does not improve with
fluid challenge. Norepinephri