Management of Intermediate-High Risk PE Patients

• Though there are varying definitions, intermediate-high risk patients with a PE are generally defined as those who are hemodynamically stable, have radiographic or laboratory evidence of right heart strain, and an elevated PE risk score.
• A few key management pearls include:
  • Be judicious with IVFs to avoid worsening septal shift and fruther decreases in LV cardiac output.
  • Consider dobutamine for severe RV dysfunction.
  • Administer norepinephrine, if needed, to achieve a MAP of 65 mm Hg.
  • Avoid initiation of positive pressure ventilation, if possible. 
  • If intubation is needed for clinical deterioriation avoid propofol for RSI.  Propofol has been associated with increased mortality in this patient population.

References

Weinstein T, et al. Advanced management of intermediate-high risk pulmonary embolism. Crit Care. 2021; 25:311.