Pulmonary thromboembolism among elderly intensive care unit patients

Introduction

The increasing life expectation has increased the number of elderly patients in the intensive care unit (ICU).

Objective

To evaluate pulmonary thromboembolism (PE) among patients older than 65 years old admitted to an ICU.

Methods

We studied a prospective cohort enrolling 1993 patients admitted to a clinical ICU (from March 2000 to February 2003). Fifty-two patients with high clinical probability of PE were submitted to several complementary examinations such as D-dimer concentration, electrocardiogram, chest radiography, arterial blood gas, echo Dopplercardiogram and venous colored echo Doppler. The PE was confirmed in 37 of those patients (of which 32 were older than 65 years old) with one of these confirmatory methods: ventilation-perfusion lung scan with a high probability result (56%), the identification of a clot by spiral computer tomography (41%), or a positive gadolinium-enhanced magnetic resonance angiography (3%).

Results

The mean age of our patients was 78 ± 5 years old (maximum 98 years) and the mean Acute Physiology and Chronic Health Evaluation II score was 11 ± 6 (maximum 20). Eighty-four percent of our patients were female, and the most prevalent risk factors were age, immobilization (31%), ejection fraction < 40% (28%), history of deep venous thrombosis (25%), and chronic pulmonary hypertension (16%). The most usual signs and symptoms were dyspnea (88%), tachypnea (78%), chest pain (34%), sinusal tachycardia (31%), cough and cyanosis (19%). The complementary examinations showed the positivity of 94% for D-dimer, 72% for venous colored echo Doppler, 67% for echo Dopplercardiogram, 66% for chest radiography and 40% for electrocardiogram. Thirty-eight percent of the patients showed hypoxemia at the arterial blood gas analysis. Unfractionated heparin was used as the first choice treatment in 72% of the patients, and thrombolitic therapy in 19%. No major bleeding episodes requiring blood transfusions were seen. The overall inhospital mortality rate was 28% (PE + septic shock), and 18% related to PE by itself. The average ICU inmate time was 6 ± 4 days (minimum 3 days and maximum 19 days) and the average time of hospitalization was 12 ± 25 days (minimum 4 days and maximum 143 days).

Conclusion

The authors warn of the necessity of a clinical suspicion of pulmonary thromboembolism as the first step of a differential diagnosis with other prevalent pathologies among the elderly, and highlight the good results with therapy, including the thrombolitics.