Pulmonary Embolism: A Common Cause of Mortality in Hospitals - Research Paper

Introduction

Pulmonary Embolism (PE) is a common condition that could lead to death or critical disability. PE occurs when there is pulmonary bed obstruction as a result of the clotting of blood within the lung arteries (Belohlavek, Dythrych, and Linhart, 2013). When PE is not diagnosed and treated at an early stage it could lead to death within a few hours. Clinical evidence ascertains that PE contributed to about 5% to 10% of mortality cases among hospitalized patients in the United States. In the United Kingdom, the incidence of PE is estimated at 0.5 to 1 person per 1000 individuals (Tsilimidos and Marinis, 2013). However, among Deep Vein Thrombosis (DVT) patients, the figures of silent PE are considered to be between 40% and 50%. It is important to point out that PE is preventable.

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The first step towards the diagnosis and treatment of PE is the immediate identification of symptoms and risks (Gromadzinski et al., 2011). The presence of D-dimers is an essential biomarker used to assess the possibility of a thrombus. The use of a CT scan is usually carried out after a contrast material injection to determine the arteries with a clot (Thieme et al., 2011). A nuclear medicine lung scan is effective in showing the position with limited blood flow. At high-risk level, anticoagulation could occur before the tests are completed. In this case, symptomatic patients require immediate hospitalization and treatment with anticoagulants (Hugli et al., 2011).

In Saudi Arabia, cases of PE have been reported in different healthcare facilities. Studies addressing the risk factors and prevalence of such cases are limited. There is a need for further studies focusing on the risk factors associated with PE across specific hospitals to recommend strategies for preventing mortality and enhancing immediate diagnosis and treatment. The present study aims to determine the prevalence of PE in King Sultan Medical City and to assess the most common risk factors to develop an early intervention for the prevention and treatment of the condition.

Literature Review

When a blood clot moves away from the location of its formation, it is dislodged to vessels where its embolism to arterial circulation occurs. According to clinical evidence assess by Tsakali et al. (2007), about 60% blockage of the pulmonary artery is blocked with the occurrence of embolism paving the way to a decline in blood pressure. A blockage of about 80% of the vascular network leads to death. Based on the scholarly evidence by Girtovitis (2014), the rate of occlusion determines the nature of cardiac hemodynamic effects. There are several effects of PE amid a lack of immediate intervention. DeLuca et al. (2012) list myocardial ischemia, acute pulmonary heart, the left-sided failure, and acute circulatory failure as the key effects of PE. At the same time, hypoxia and atelectasis have been identified as part of the lungs-based pathophysiological effects of the condition.

Studies on the course of PE have presented significant clinical outcomes. Necrosis of the tissues of the lungs is one of the outcomes that immediately follow PE. Although rare, about 10% of the cases have been linked to Necrosis of lungs (Akiros, 2009). According to Stagaki et al. (2012), after 10 to 14 days, the clot could be converted into a scar adherent on the walls of the vascular tissue after embolus installation. When such re-establishment fails to take place, Mandala and Lafaras (2010) postulated that collateral bronchial movement development restores the circulation within the capillaries.

Additionally, evidence from clinical picture displaying instances of PE has significantly shown a high level of variations. Mismetti and Bertoletti (2015) found out that the number of branches within the pulmonary vascular network as well as the size relates to the presented symptoms and pathophysiology of PE. Patients could present dyspnea that slowly advances to a critical stage or they could gradually experience severe symptoms that permits cessation of pulmonary functionality. Cardiac function disorders, in this case, lead to profound symptoms especially in massive PE, which has been associated with immediate acute myocardial-like pain (Akiros, 2009). Tachycardia, shortness of breath, pulmonary infarction, a decline in blood pressure, restlessness, electrocardiographic changes, and sweating have been equally reported as part of the PE presentation.

Additionally, scholars have also been keen on PE diagnosis interventions. Since it is not easy to immediately diagnose PE, practitioners have been encouraged to always consider the possibility of PE when dealing with an acute lung etiology case. The presence of localized wheezing, abdominal gallop, atelectatic crackles, tachycardia, and occlusal pulmonary artery sound are all factors that indicate a possible PE. A systolic murmur in the chest because of turbulent flows could be heard (Stagaki et al., 2012). According to Akiros (2009), physical indicators should be sought including deep vein thrombosis, which is highly probable. The patient could also depict elevated levels of serum bilirubin and lactic deideogenasi. Normal GOT, low PO2, and chest X-ray could further confirm the condition. ECG checks and electrocardiogram reviews could also be used to confirm a PE case. Nevertheless, during diagnosis, the time factor is critical, especially in severe cases.

Studies on PE treatment have pointed out how surgical or conservative interventions are essential. Examples of conservative treatment options include the use of anticoagulants, antibiotics, circulation support, analgesics, and thrombolytics (Mismetti and Bertoletti, 2015). The use of Heparin prevents further increase in thrombus size while facilitating the dissolution process of the fibrinolytic system; however, the use of this intervention does not eliminate the existing clots. A side effect of heparin has been thee danger associated with possible bleeding instances. On the other hand, Warfarin is a recommended treatment for PE since it is a Vitamin K antagonist. Thrombolysis has also been identified as a treatment intervention that reverses experienced heart failure. Recurrence of PE is treated with heparin and warfarin-based anticoagulation. The purpose of the treatment interventions is to remove the clot and restore pulmonary functionality.

Moreover, several scholars have investigated the common risk factors have been associated with PE. According to Morrone and Morrone (2018), people with obesity are a higher risk of PE. Immobilization and cigarette use have also been linked to PE diagnostic prevalence. Trauma, cancer, and surgery have also been a precursor to multiple PE diagnoses and deaths. Other risk factors identified through clinical evidence include hormone replacement therapies as well as contraceptives and pregnancy. A previous history of PE or a prior instance of hype-coagulative disorder could equally put an individual at a higher PE risk. Nevertheless, about 30% of PE patients have not directly presented provoking risk factors. However, according to three major PE registries, which are RIETE, EMPORER, and ICOPER, the average age of the diagnosed individual is between 56 and 66 (Babak and Sriram, 2014).

Furthermore, several studies are focusing on different aspects of PE in Saudi Arabia. Algahtani et al. (2012) examined the clinical characteristics associated with PE as well as the risk factors based on the data collected from the Saudi tertiary care facility. The scholars assessed 341 PE suspected cases where only 68 were actual diagnosis while the remaining 273 were differential diagnoses. The study found out that the common risk factors associated with PE included diabetes and recent surgery at 26.1% and 21.7% respectively. Other risk factors presented in this study include obesity, transient immobility, and heart failure. However, these five factors were not primarily associated with PE occurrence. Further details from the study ascertained that antiphospholipid syndrome, systemic lupus erythematous, factor V Leiden, hyperhomocysteinemia, liver disease, and oral contraceptive had a relationship with positive PE diagnosis. Although the study was comprehensive, the researchers did not offer strategic implementations to enhance the prevention and effective and immediate diagnosis.

Nesriene et al. (2017) also carried a study regarding the incidence of PE in Saudi Arabia. The study that was focused on King Faisal Hospital investigated the rate of incidence associated with PE in the facility. The data were obtained between June 2016 and December 2016. The scholars used a cross-sectional approach to assess 20 patients who were diagnosed with the condition during the six months. Based on the findings, the study concluded that the incidence rate stands at 5.5%. At the same time, several risk factors were identified with different magnitude in terms of prevalence and presentation. For example, about 25% of diagnosed individuals were smokers. Oral contraceptives, traveling history, and cancer also featured in the study. One key limitation of this research was the limited number of samples and the lack of comprehensive assessment of patients' risk factors.

Additionally, another study based on Saudi was conducted by Saleh et al. (2016). In their study, Saleh et al. (2016) assessed the probability of death in diagnosed PE. The data collected from ICU cases was used to determine the clinical probability. The study found out that the overall ICU mortality rate in the country stood at 15%; however, PE -specific death rate was 25% of the ICU cases. Prolonged immobility was considered the highest predisposing factor of PE prevalence at 45.3%. The findings of the study provided relevant to the development of integrated demographic interventions to reduce predisposing factors. Multidimensional diagnostic and treatment options for effective patient outcomes were not incorporated into this study.

From the review of the literature, it is evident that there is a need for further studies focusing on risk factors, treatment and diagnostic interventions, and prevention mechanisms. However, in Saudi Arabia, the studies have not been comprehensive. Most studies have been characterized by small sample sizes as well as limited risk factor assessment. The limited data has been fostered by a lack of access to a national database system that could enable researchers to analyze evidence from a significantly high number of patients. Therefore, this current study seeks to fill these gaps by investigating the risk factors associated with PE and recommend the establishment of the King Sultan Medical City database.

References

Akiros, D., 2009. Handbook of cardiology nursing. Medical Publications: Parisianow.

AlGahtani, F. H., Bayoumi, N., Abdelgadir, A., Al-Nakshabandi, N., Al Aseri, Z., Al Ghamdi, M., and Al Saeed, E., 2012. Clinical Characteristics and risk factors of pulmonary embolism: data from a Saudi tertiary-care center. J Thromb Haemost, Vol. 18, pp. 1 - 3. Doi: 10.1111/jth.12025.

Babak, S. and Sriram, K. B., 2014. "Misinterpreting risk and test results delays diagnosis in a patient with pulmonary embolism." BMJ Case Rep, bcr2014204172.

Belohlavek, J., Dythrych, V., and Linhart, A., 2013. Pulmonary embolism, part I: Epidemiology, risk factors and risk stratification, pathophysiology, clinical presentation, diagnosis, and non-thrombotic pulmonary embolism. Exp Clin Cardiol, Vol 18, Iss. 2, pp. 129 - 139.

DeLuca, E., Watson, A., and Osborn, K., 2012. Pulmonary Embolism. Publishing Pachalidis.

Girtovitis, F., 2014. "Prevention and treatment of th...