What are the intensive care unit (ICU) admission criteria for pulmonary embolism (PE)?

From the Guidelines

Patients with pulmonary embolism (PE) should be admitted to the ICU if they have high-risk features, including hemodynamic instability, cardiac arrest, obstructive shock, or persistent hypotension, as defined by the 2019 ESC guidelines 1. The criteria for ICU admission include:

• Hemodynamic instability, defined as systolic blood pressure <90 mmHg or vasopressors required to achieve a blood pressure >90 mmHg despite adequate filling status, in combination with end-organ hypoperfusion
• Cardiac arrest
• Obstructive shock
• Persistent hypotension, defined as systolic blood pressure <90 mmHg or a systolic blood pressure drop >40 mmHg for >15 minutes, not caused by new-onset arrhythmia, hypovolemia, or sepsis
• Evidence of right ventricular dysfunction on echocardiography or computed tomography pulmonary angiography (CTPA)
• Elevated cardiac biomarkers, such as troponin or B-type natriuretic peptide (BNP) The 2019 ESC guidelines also recommend using the Pulmonary Embolism Severity Index (PESI) or simplified PESI (sPESI) to assess the risk of early mortality in patients with PE 1. Patients with intermediate-high-risk PE, defined as those with evidence of right ventricular dysfunction and elevated cardiac biomarkers, should also be considered for ICU admission, as they have a higher risk of hemodynamic decompensation and may require close monitoring and advanced interventions 1. In addition, patients with massive PE, defined as those with obstruction of >50% of the pulmonary circulation or involvement of two or more lobar arteries, or submassive PE with signs of right ventricular dysfunction, should also be considered for ICU admission 1. The rationale for ICU admission is that these patients require close hemodynamic monitoring, may need advanced interventions like mechanical circulatory support, and have a higher risk of rapid deterioration, with mortality rates for massive PE exceeding 30% without appropriate intensive care 1. Treatment in the ICU typically includes anticoagulation, consideration of thrombolysis, and supportive care, including careful fluid management and vasopressor support if needed 1.

From the Research

ICU Admission Criteria for Pulmonary Embolism (PE)

The decision to admit a patient with pulmonary embolism (PE) to the intensive care unit (ICU) is based on several factors, including the severity of the condition and the presence of certain risk factors. Some of the key considerations include:

• Hemodynamic instability, such as hypotension, which is a significant predictor of poor outcome and defines those with massive PE 2
• Evidence of right ventricular (RV) dysfunction, as assessed by echocardiography, which comprises the sub-massive category and is at intermediate risk of poor outcomes 2, 3
• Presence of cardiac troponin, brain natriuretic peptide, and computed tomographic pulmonary angiography, which can raise the suspicion that a patient has sub-massive PE 2
• Advanced age and concomitant cardiopulmonary disease, which are clinical risk factors for in-hospital mortality 4
• Elevated serum levels of troponins, which have been shown to be associated with right ventricular overload and adverse in-hospital outcomes in patients with pulmonary embolism 4

Risk Stratification

Risk stratification is critical in determining the appropriate level of care for patients with PE. The following categories are commonly used:

• Massive PE: characterized by hemodynamic instability, such as hypotension, and a high risk of mortality 2, 5
• Sub-massive PE: characterized by evidence of right ventricular dysfunction, but without hemodynamic instability, and an intermediate risk of mortality 2, 3
• Low-risk PE: characterized by the absence of hemodynamic instability and right ventricular dysfunction, and a low risk of mortality 2

Management

The management of PE in the ICU depends on the severity of the condition and the presence of certain risk factors. Some of the key considerations include:

• Anticoagulation, which is the initial therapy for patients with PE 2
• Thrombolysis, which is recommended for patients with massive PE and may be considered for patients with sub-massive PE 2, 5
• Use of vasopressors, inotropes, pulmonary artery (PA) vasodilators, and mechanical ventilation to stabilize critically ill patients 2
• Surgical embolectomy and catheter-based therapies, which may be considered for patients with contraindications to anticoagulation and thrombolytic therapy 2