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Intensivmedizin up2date 2005; 1(3): 189-203
DOI: 10.1055/s-2005-870106
Allgemeine Prinzipien der Intensivmedizin
© Georg Thieme Verlag KG Stuttgart · New York

Lungenembolie

Sabine  Oldenburg, Birgitt  Pfeiffer, Thomas  Hachenberg
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Publication History

Publication Date:
08 August 2005 (online)

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Kernaussagen

Die akute LE bleibt auch 40 Jahre nach Einführung der Heparintherapie eine potenziell lebensbedrohliche Erkrankung mit einer Letalität von etwa 10 %. Der kritische Faktor ist die schnelle und sichere Diagnostik. Dabei wird neuerdings der Spiral-CT eine größere Bedeutung beigemessen, die mit der Verbreitung der Multidetectoring-Spiral-CT weiter zunehmen wird.

Die Indikation zur Lysetherapie ist weiterhin auf die massive LE mit instabiler Hämodynamik (sicher) oder echokardiographischer rechtsventrikulärer Dysfunktion (kontrovers) beschränkt. Für die submassive LE ist ein Vorteil der Lysetherapie gegenüber der alleinigen Antikoagulation nicht nachgewiesen. Unter Reanimationsbedingungen ist die Lyse bereits beim Verdacht auf eine LE durchzuführen. Die Lyse sollte grundsätzlich als Bolus- oder Kurzzeitlyse durchgeführt werden, wobei rt-PA bevorzugt wird.

Die aktuellen Leitlinien sind:

European Society of Cardiology: Guidelines on diagnosis and management of acute pulmonary embolism (2000) [26]

Leitlinie der Deutschen Gesellschaft für Angiologie: Diagnostik und Therapie der Venenthrombose und LE (2005) [42]

American Collage of Emergency Physicians: Clinical policy: Critical issues in the evaluation and management of adult patients presenting with suspected pulmonary embolism (2003) [25]

British Thoracic Society: Guidelines for the mangement of suspected acute pulmonary embolism (2003) [1]

Literatur

  • 1 British Thoracic Society. British Thoracic Society guidelines for the management of suspected acute pulmonary embolism.  Thorax. 2003;  58 470-483
    CrossrefPubMedGoogle Scholar
  • 2 Barrit D W, Jordan S C. Anticoagulant drugs in the treatment of pulmonary embolism.  Lancet. 1960;  1 1309-1312
    PubMedGoogle Scholar
  • 3 Chagnon I, Bounameaux H, Aujesky D. et al . Comparison of two clinical prediction rules and implicit assessment among patients with suspected pulmonary embolism.  Am J Med. 2002;  113 269-275
    CrossrefPubMedGoogle Scholar
  • 4 Wells P, Anderson D, Rodger M. et al . Derivation of a simple clinical model to categorize patients probability of pulmonary embolism: increasing the models utility with the SimpliRED D-dimer.  Thromb Haemost. 2000;  83 416-420
    Article in Thieme ConnectPubMedGoogle Scholar
  • 5 Hull R, Raskob G, Ginsberg J. et al . A noninvasive strategy for the treatment of patients with suspected pulmonary embolism.  Arch Intern Med. 1994;  154 289-297
    CrossrefPubMedGoogle Scholar
  • 6 Kline J, Hernandez-Nino J, Newgard C. et al . Use of pulse oximetry to predict in-hospital complications in normotensive patients with pulmonary embolism.  Am J Med. 2003;  115 203-208
    CrossrefPubMedGoogle Scholar
  • 7 Janata K, Holzer M, Domanovits H. et al . Mortality of patients with pulmonary embolism.  Wien Klin Wochenschr. 2002;  114 766-772
    PubMedGoogle Scholar
  • 8 Meneveau N, Ming L P, Seronde M F. et al . In-hospital and long-term outcome after sub-massive and massive pulmonary embolism submitted to thrombolytic therapy.  Eur Heart J. 2003;  24 1447-1454
    CrossrefPubMedGoogle Scholar
  • 9 Liu P, Meneveau N, Schiele F. et al . Predictors of long-term clinical outcome of patients with acute massive pulmonary embolism after thrombolytic therapy.  Chin Med J (Engl). 2003;  116 503-509
    PubMedGoogle Scholar
  • 10 Kasper W, Geibel A, Tiede N. et al . Patent foramen ovale in patients with haemodynamically significant pulmonary embolism.  Lancet. 1992;  340 561-564
    CrossrefPubMedGoogle Scholar
  • 11 Bottiger B. Lungenembolie. In: Eckart J, Forst H, Burchardi H, eds Intensivmedizin. Landsberg; ecomed 2001: III-21
    Google Scholar
  • 12 Mehta N, Jani K, Khan I. Clinical usefulness and prognostic value of elevated cardiac troponin I levels in acute pulmonary embolism.  Am Heart J. 2003;  145 821-825
    CrossrefPubMedGoogle Scholar
  • 13 Kucher N, Wallmann D, Carone A. et al . Incremental prognostic value of troponin I and echocardiography in patients with acute pulmonary embolism.  Eur Heart J. 2003;  24 1651-1656
    CrossrefPubMedGoogle Scholar
  • 14 Masotti L, Ceccarelli E, Forconi S. et al . Diagnostic and therapeutic features of pulmonary embolism in elderly patients.  Ital Heart J. 2003;  Suppl 4 745-754
    PubMedGoogle Scholar
  • 15 Hull R, Raskob G, Brant R. et al . Low-molecular-weight heparin vs heparin in the treatment of patients with pulmonary embolism. American-Canadian Thrombosis Study Group.  Arch Intern Med. 2000;  160 229-236
    CrossrefPubMedGoogle Scholar
  • 16 Kulstad E B, Kulstad C E, Lovell E O. A rapid quantitative turbimetric d-dimer assay has high sensitivity for detection of pulmonary embolism in the ED.  Am J Emerg Med. 2004;  22 111-114
    CrossrefPubMedGoogle Scholar
  • 17 Schoepf U J, Costello P. CT angiography for diagnosis of pulmonary embolism: state of the art.  Radiology. 2004;  230 329-337
    CrossrefPubMedGoogle Scholar
  • 18 Couturaud F, Kearon C, Bates S. et al . Decrease in sensitivity of D-dimer for acute venous thromboembolism after starting anticoagulant therapy.  Blood Coagul Fibrinolysis. 2002;  13 241-246
    CrossrefPubMedGoogle Scholar
  • 19 Carman T, Deitcher S. Advances in diagnosing and excluding pulmonary embolism: spiral CT and D-dimer measurement.  Cleve Clin J Med. 2002;  69 721-729
    PubMedGoogle Scholar
  • 20 Irwin G, Luchs J, Donovan V. et al . Can a state-of-the-art D-dimer test be used to determine the need for CT imaging in patients suspected of having pulmonary embolism?.  Acad Radiol. 2002;  9 1013-1017
    CrossrefPubMedGoogle Scholar
  • 21 Stein P, Athanasoulis C, Alavi A. et al . Complications and validity of pulmonary angiography in acute pulmonary embolism.  Circulation. 1992;  85 462-468
    PubMedGoogle Scholar
  • 22 de Monye W, van Strijen M J, Huisman M V. et al . Suspected pulmonary embolism: prevalence and anatomic distribution in 487 consecutive patients. Advances in New Technologies Evaluating the Localisation of Pulmonary Embolism (ANTELOPE) Group.  Radiology. 2000;  215 184-188
    PubMedGoogle Scholar
  • 23 Kroegel C. Advances in the diagnosis and treatment of pulmonary embolism. Pulmonary embolism - how can you mend a broken clot?.  Respiration. 2003;  70 4-6
    CrossrefPubMedGoogle Scholar
  • 24 Nijkeuter M, Huisman M V. Pentasaccharides in the prophylaxis and treatment of venous thromboembolism: a systematic review.  Curr Opin Pulm Med. 2004;  10 338-344
    CrossrefPubMedGoogle Scholar
  • 25 American College of Emergency Physicians Clinical Policies Committee; Clinical Policies Committee Subcommittee on Suspected Pulmonary Embolism . Clinical policy: critical issues in the evaluation and management of adult patients presenting with suspected pulmonary embolism.  Ann Emerg Med. 2003;  41 257-270
    PubMedGoogle Scholar
  • 26 Torbicki A, van Beek E JR, Charbonnier B. et al . Task Force Report. Guidelines on diagnosis and management of acute pulmonary embolism.  European Heart Journal. 2000;  21 1301-1336
    CrossrefPubMedGoogle Scholar
  • 27 de Monye W, Sanson B J, Mac Gillavry M R. et al . Embolus location affects the sensitivity of a rapid quantitative D-dimer assay in the diagnosis of pulmonary embolism.  Am J Respir Crit Care Med. 2002;  165 345-348
    PubMedGoogle Scholar
  • 28 Ferretti G, Bosson J, Buffaz P. et al . Acute pulmonary embolism: role of helical CT in 164 patients with intermediate probability at ventilation-perfusion scintigraphy and normal results at duplex US of the legs.  Radiology. 1997;  205 453-458
    PubMedGoogle Scholar
  • 29 Gottsater A, Berg A, Centergard J. et al . Clinically suspected pulmonary embolism: is it safe to withhold anticoagulation after a negative spiral CT?.  Eur Radiol. 2001;  11 65-72
    CrossrefPubMedGoogle Scholar
  • 30 Gottschalk A, Stein P, Goodman L. et al . Overview of Prospective Investigation of Pulmonary Embolism Diagnosis II.  Semin Nucl Med. 2002;  32 173-182
    CrossrefPubMedGoogle Scholar
  • 31 Rathbun S W, Whitsett T L, Vesely S K. et al . Clinical utility of D-dimer in patients with suspected pulmonary embolism and nondiagnostic lung scans or negative CT findings.  Chest. 2004;  125 851-855
    CrossrefPubMedGoogle Scholar
  • 32 Agnelli G, Becattini C, Kirschstein T. Thrombolysis vs heparin in the treatment of pulmonary embolism: a clinical outcome-based meta-analysis.  Arch Intern Med. 2002;  162 2537-2541
    CrossrefPubMedGoogle Scholar
  • 33 Kanne J P, Lalani T A. Role of computed tomography and magnetic resonance imaging for deep venous thrombosis and pulmonary embolism.  Circulation. 2004;  109 I15-21
    CrossrefPubMedGoogle Scholar
  • 34 Kruip M, Leclercq M, van dHC . et al . Diagnostic strategies for excluding pulmonary embolism in clinical outcome studies. A systematic review.  Ann Intern Med. 2003;  138 941-951
    CrossrefPubMedGoogle Scholar
  • 35 Kearon C. Diagnosis of pulmonary embolism.  CMAJ. 2003;  168 183-194
    PubMedGoogle Scholar
  • 36 Konstantinides S, Geibel A, Heusel G. et al . Heparin plus alteplase compared with heparin alone in patients with submassive pulmonary embolism.  N Engl J Med. 2002;  347 1143-1150
    CrossrefPubMedGoogle Scholar
  • 37 Kucher N, Luder C, Dornhofer T. et al . Novel management strategy for patients with suspected pulmonary embolism.  Eur Heart J. 2003;  24 366-376
    PubMedGoogle Scholar
  • 38 Brower R, Shanholtz C, Fessler H. et al . Prospective, randomized, controlled clinical trial comparing traditional versus reduced tidal volume ventilation in acute respiratory distress syndrome patients.  Crit Care Med. 1999;  27 1492-1498
    CrossrefPubMedGoogle Scholar
  • 39 Mercat A, Diehl J, Meyer G. et al . Hemodynamic effects of fluid loading in acute massive pulmonary embolism.  Crit Care Med. 1999;  27 540-544
    CrossrefPubMedGoogle Scholar
  • 40 van Strijen M J, de Monye W, Kieft G J. et al . Diagnosis of pulmonary embolism with spiral CT as a second procedure following scintigraphy.  Eur Radiol. 2003;  13 1501-1507
    CrossrefPubMedGoogle Scholar
  • 41 Wicki J, Perneger T, Junod A. et al . Assessing clinical probability of pulmonary embolism in the emergency ward: a simple score.  Arch Intern Med. 2001;  161 92-97
    CrossrefPubMedGoogle Scholar
  • 42 Hach-Wunderle V. Interdisziplinäre SZ-Leitlinie. Venenthrombose und Lungenembolie.  VASA. 2005;  34 Suppl. 66
    PubMedGoogle Scholar
  • 43 Reynolds N A, Perry C M, Scott L J. Fondaparinux sodium: a review of its use in the prevention of venous thromboembolism following major orthopaedic surgery.  Drugs. 2004;  64 1575-1596
    PubMedGoogle Scholar

Prof. Dr. med. Dr. Thomas Hachenberg

Universitätsklinik für Anästhesiologie und Intensivtherapie · Otto-von-Guericke-Universität Magdeburg

Leipziger Str. 44 · 39120 Magdeburg

Phone: 0391/6 71 35 00

Fax: 03 91/6 71 35 01

Email: thomas.hachenberg@medizin.uni-magdeburg.de

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