Fluid Therapy
- Cautious fluid therapy 1 may improve haemodynamic status:
- Small fluid boluses (500ml) have been shown to improve cardiac output
- Aggressive volume expansion should be avoided: 1
- Potential to over distend the RV and lead to reduced systemic cardiac output
- Not shown to be of benefit in studies and may be harmful
- If signs of elevated CVP, further volume loading should be withheld
Vasopressors & Inotropes
- Noradrenaline considered as first line therapy: 1
- Increases RV inotropy and systemic blood pressure
- Restores coronary perfusion gradient and improves ventricular interactions
- Dobutamine may be considered useful for patients with PE, a low cardiac index and normal: 1
- Potential to aggravate ventilation/perfusion mismatch
- Can worsen circulatory failure given vasodilatory effect
Pulmonary Vasodilators
- Pulmonary vasodilators may be useful in in patients with PE and pulmonary hypertension 1 , though anecdotal evidence only
- Options include inhaled nitric oxide and aerosolised prostacyclin
Mechanical Circulatory Support
- Mechanical support may be useful in the setting of circulatory collapse or cardiac arrest: 1
- VA-ECMO most frequently used:
- Associated with a high incidence of complications, even when used for short periods
- Effectiveness depends upon centre experience and patient selection