2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the ...
Acute Pulmonary Embolism
Clinical SnapshotDtsch Arztebl Int 2017; 114: 398. DOI: 10.3238/arztebl.2017.0398
Frölich, A; Neumann, C
Figure
Pulmonary perfusion scintigraphy
An 87-year-old man presented in poor overall condition because of progressively severe dyspnea of 10 days' duration. He underwent pulmonary perfusion scintigraphy. The image shows a nearly total absence of perfusion of the right upper lobe and of multiple other regions in both lungs. In particular, the clearly circumscribed perfusion deficit on the right was pathognomonic for pulmonary embolism. Accordingly, the lung perfusion fractions were abnormally asymmetric— 67% on the left and 33% on the right. Low-molecular-weight heparin was given and the patient was urgently admitted to the hospital. A further study revealed a four-level deep venous thrombosis of the left lower limb as the source of the massive pulmonary arterial embolus. This case illustrates the key role of scintigraphy in the sequence of diagnostic tests for pulmonary embolism. Despite the severity of this patient's problem, a rapid and sensitive diagnostic study enabled the immediate initiation of appropriate treatment, with a successful outcome.
Dr. Med. Anne Frölich, Christoph Neumann, Praxis für Nuklearmedizin, Leipzig,annefroelich@me.Com
Conflict of interest statementThe authors declare that no conflict of interest exists.
Cite this as: Frölich A, Neumann C: Acute pulmonary embolism. Dtsch Arztebl Int 2017; 114: 398. DOI: 10.3238/arztebl.2017.0398
Translated from the original German by Ethan Taub, M.D.
Figure
Pulmonary perfusion scintigraphy
Pulmonary Embolism During COVID Infection A Deadly Mix
HONOLULU -- During the first year of the pandemic, patients with pulmonary embolism (PE) had higher in-hospital mortality rates when they also had concomitant COVID-19, according to a nationwide retrospective cohort study.
Using data from the 2020 National Inpatient Sample Database (NIS), 19.8% of patients with both PE and COVID died in the hospital compared with 7.1% of those with PE but without COVID (adjusted OR 3.16, 95% CI 3.07-3.25, P<0.001), reported Rana Prathap Padappayil, MBBS, of Upstate Medical University in Syracuse, New York, during the CHEST annual meeting hosted by the American College of Chest Physicians.
Patients with PE who had COVID were also more likely to require vasopressors (5.31% vs 2.66%; aOR 1.16, 95% CI 1.11-1.22) and extracorporeal membrane oxygenation (0.76% vs 0.30%; aOR 1.62, 95% CI 1.41-1.86), and had longer lengths of stay (7 vs 4 days; P<0.001).
Padappayil noted that acute PE is one of the most common causes of cardiovascular death, with in-hospital mortality rates of around 30%. Studies have shown that COVID is an independent risk factor for developing PE.
Of note, patients with both PE and COVID were less likely to receive certain procedures versus those without COVID, including systemic thrombolysis (2.83% vs 4.71%), catheter-directed thrombolysis (0.13% vs 0.49%), and thrombectomy (0.73% vs 1.94%; all P<0.001).
Because the study data are from 2020 -- the first year of the pandemic -- this may have played a role in the differences among procedure utilization, Padappayil said, noting that a lack of personal protective equipment, a high patient burden, and concerns about evidence likely resulted in patients with both PE and COVID receiving fewer interventions compared with those without COVID.
However, it is unclear if this lack of interventions resulted in higher mortality in patients with PE and COVID, he added.
For this study, the researchers used data from the NIS, which included 425,640 hospitalizations for acute PE (the admitting diagnosis); 11% of these patients also had a COVID-19 infection.
Median patient age was 65, and the majority were women (41.6% with COVID and 50.6% without COVID) and white (53.4% and 70%, respectively); 23% and 19% were African American and 16.4% and 6.7% were Hispanic.
Among the comorbidities present among the patient population were hypertension (62% in both groups), smoking (20% with COVID and 23% without), chronic obstructive pulmonary disease (COPD; 21.6% and 27%, respectively), congestive heart failure (16.5% and 24%), diabetes (13.7% and 10.7%), malignancy (4.1% and 16.6%), and history of venous thromboembolism (4.5% and 9.4%).
Padappayil and team noted that patients with PE and COVID were more likely to be men and non-white, and less likely to have comorbidities, including prior myocardial infarction, diabetes, congestive heart failure, COPD, chronic kidney disease, end-stage renal disease, malignancy, and history of venous thromboembolism.
Limitations to the study included the fact that the NIS database is subject to selection biases and ICD miscoding. In addition, the analysis was limited to in-hospital outcomes, which means the researchers were unable to assess long-term outcomes after discharge.
Padappayil stressed the need for further research using data from the subsequent years of the pandemic. As NIS data become available, his group will look into whether providers have been more willing to use thrombolysis and thrombectomy in patients with both PE and COVID.
Elizabeth Short is a staff writer for MedPage Today. She often covers pulmonology and allergy & immunology. Follow
Disclosures
Padappayil reported no disclosures.
Primary Source
CHEST
Source Reference: Padappayil RP, et al "Concomitant COVID-19 infection and pulmonary embolism: incidence and in-hospital outcomes in a nationwide cohort" CHEST 2023.
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American Regent Introduces Potassium Phosphates, USP; FDA-Approved And "AP" Rated¹
SHIRLEY, N.Y., Oct. 19, 2023 /PRNewswire/ -- American Regent announces the launch and availability of Potassium Phosphates Injection, USP, which is FDA-approved and therapeutically equivalent to Potassium Phosphates.1 Potassium Phosphates Injection, USP is indicated as a source of phosphorus:
"An important part of our company's mission is to assist in mitigating shortages and ensuring supply of critical medications whenever possible. To that end, we are pleased to add Potassium Phosphates Injection, USP to our robust line of products that are formulated, filled, and finished at our US-based manufacturing facilities," stated Joann Gioia, Vice President and Chief Commercial Officer at American Regent, Inc.
This product is available for immediate shipment. Customers can order Potassium Phosphates Injection, USP, through their wholesaler/distributor, or by contacting our Customer Support Group at 1-800-645-1706.
Potassium Phosphates Injection, USP is supplied as follows:
Pack NDC# Strength Supplied as Shelf pack 0517-2051-25 Phosphorus 15 mmol/5 mL and Potassium 22 mEq/5 mL 5 mL Single-dose, plastic vial 25 0517-2102-25 Phosphorus 45 mmol/15 mL and Potassium 66 mEq/15 mL 15 mL Single-dose, plastic vial 25 0517-2505-25 Phosphorus 150 mmol/50 mL and Potassium 220 mEq/50 mL 50 mL Pharmacy Bulk Package, plastic vial 25See the following Important Safety Information, in addition to the product's Full Prescribing Information.
For additional information, please visit www.Americanregent.Com.
Potassium Phosphates Injection, USPFor intravenous use
INDICATIONS AND USAGE
Potassium Phosphates Injection is indicated as a source of phosphorus:
IMPORTANT SAFETY INFORMATION
CONTRAINDICATIONS
Potassium Phosphates Injection is contraindicated in patients with: hyperkalemia; hyperphosphatemia; hypercalcemia or significant hypocalcemia; severe renal impairment (eGFR less than 30 mL/min/1.73m2) or end stage renal disease.
WARNINGS AND PRECAUTIONS
Serious Cardiac Adverse Reactions with Undiluted, Bolus, or Rapid Intravenous Administration: Intravenous administration of potassium phosphates to correct hypophosphatemia in single doses of phosphorus 50 mmol and greater and/or at rapid infusion rates (over 1 to 3 hours) in intravenous fluids has resulted in death, cardiac arrest, cardiac arrhythmia (including QT prolongation), hyperkalemia, hyperphosphatemia, and seizures. In addition, inappropriate intravenous administration of undiluted or insufficiently diluted potassium phosphates as a rapid "IV push" has resulted in cardiac arrest, cardiac arrhythmias, hypotension, and death. Administer only after dilution or admixing; do not exceed the recommended infusion rate. Continuous electrocardiographic (ECG) monitoring may be needed during infusion.
Pulmonary Embolism due to Pulmonary Vascular Precipitates: Pulmonary vascular emboli and pulmonary distress related to precipitates in the pulmonary vasculature have been described in patients receiving admixed products containing calcium and phosphate or parenteral nutrition. If signs of pulmonary distress occur, stop the infusion and initiate a medical evaluation.
Hyperkalemia: Potassium Phosphates Injection may increase the risk of hyperkalemia, including life-threatening cardiac events, especially when administered in excessive doses, undiluted or by rapid intravenous infusion. Increased risk in patients with renal impairment, severe adrenal insufficiency, or treated with drugs that increase potassium. Patients with cardiac disease may be more susceptible. Do not exceed the maximum daily amount of potassium or the recommended infusion rate. Continuous ECG monitoring may be needed during infusion.
Hyperphosphatemia and Hypocalcemia: Hyperphosphatemia can occur with intravenous administration of potassium phosphates, especially in patients with renal impairment. Hyperphosphatemia can cause the formation of insoluble calcium phosphorus products with consequent hypocalcemia, neurological irritability with tetany, nephrocalcinosis with acute kidney injury and more rarely, cardiac irritability with arrhythmias. Monitor serum phosphorus and calcium concentrations during and following infusion.
Aluminum Toxicity: Potassium Phosphates Injection contains aluminum that may be toxic. Patients with renal impairment, including preterm infants, can accumulate aluminum at levels associated with central nervous system and bone toxicity.
Hypomagnesemia: Reported in patients with hypercalcemia and diabetic ketoacidosis. Monitor serum magnesium concentrations during treatment.
Vein Damage and Thrombosis: Potassium Phosphates Injection must be diluted and administered in intravenous fluids or used as an admixture in parenteral nutrition. It is not for direct intravenous infusion. The infusion of hypertonic solutions into a peripheral vein may result in vein irritation, vein damage, and/or thrombosis.
Laboratory MonitoringMonitor serum phosphorus, potassium, calcium and magnesium concentrations during treatment.
ADVERSE REACTIONSAdverse reactions include hyperkalemia, hyperphosphatemia, hypocalcemia, and hypomagnesemia.
The following clinically significant adverse reactions are described elsewhere in the labeling: Aluminum Toxicity; Hypomagnesemia; Vein Damage and Thrombosis
DRUG INTERACTIONSOther Products that Increase Serum Potassium - Administration of Potassium Phosphates Injection to patients treated concurrently or recently with products that increase serum potassium increases the risk of severe and potentially fatal hyperkalemia, in particular in the presence of other risk factors for hyperkalemia. Avoid use of Potassium Phosphates Injection in patients receiving such products. If use cannot be avoided, closely monitor serum potassium concentrations.
USES IN SPECIFIC POPULATIONSLactation - Phosphorus and potassium are present in human milk. Administration of the recommended dose of Potassium Phosphates Injection is not expected to cause harm to a breastfed infant. There is no information on the effects of potassium phosphates on milk production. The development and health benefits of breastfeeding should be considered along with the mother's clinical need for Potassium Phosphates Injection and any potential adverse effects on the breastfed child or from the underlying maternal condition.
Pediatric Use - Because of immature renal function, preterm infants receiving prolonged parenteral nutrition treatment with Potassium Phosphates Injection may be at higher risk of aluminum toxicity.
Geriatric Use - Dose selection of Potassium Phosphates Injection for an elderly patient should be cautious, starting at the low end of the dosing range. It may be useful to monitor renal function during treatment.
Renal Impairment - Potassium and phosphorus are known to be substantially excreted by the kidney and the risk of adverse reactions to Potassium Phosphates Injection may be greater in patients with impaired renal function. Use is contraindicated due to the risk of hyperkalemia in patients with severe renal impairment (eGFR less than 30 mL/min/1.73 m2) or end stage renal disease. In patients with moderate renal impairment (eGFR ≥ 30 mL/min/1.73 m2 to < 60 mL/min/1.73 m2), start at the low end of the dosage range and monitor serum potassium, phosphorus, calcium, and magnesium concentrations.
OVERDOSAGEHyperphosphatemia - Administration of excessive doses of intravenous potassium phosphates in intravenous fluids and/or at rapid infusion rates has resulted in death, cardiac arrest, cardiac arrhythmia (including QT prolongation), hyperkalemia, hyperphosphatemia, seizures, and tetany.
Hyperkalemia - Excessive administration of phosphates given as potassium salts may also cause hyperkalemia. Manifestations of hyperkalemia include: disturbances in cardiac conduction and arrhythmias, including bradycardia, heart block, asystole, ventricular tachycardia, ventricular fibrillation; hypotension; muscle weakness including paresthesia, muscular and respiratory paralysis.
Management - In the event of overdosage, discontinue infusions containing potassium phosphates immediately and institute general supportive measures, including ECG monitoring, laboratory monitoring, and correction of serum electrolyte concentrations, especially potassium, phosphorus, calcium, and magnesium.
For additional safety information, please see Full Prescribing Information.
You are encouraged to report adverse drug events to American Regent, Inc. At 1-800-734-9236 or to the FDA by visiting www.Fda.Gov/medwatch or calling 1-800-FDA-1088.
REF-2383 2/2022
You are encouraged to report adverse drug events (ADEs) to American Regent:T 1.800.734.9236; E pv@americanregent.Com; F 1.610.650.0170
ADEs may also be reported to the FDA:1.800.FDA.1088or www.Fda.Gov/medwatch
Medical Information:T 1.888.354.4855(9:00 am–5:00 pm Eastern Time, Monday–Friday)www.Americanregent.Com/medical-affairs
For medical information outside of normal business hoursthat cannot wait until the next business day, please call 1.877.845.6371
About American RegentAmerican Regent, Inc.®, a Daiichi Sankyo Group company, is an industry-leading injectable manufacturer. For over 50 years, American Regent has been developing, manufacturing, and supplying quality generic and branded injectables for healthcare providers. For more than 20 years, we have been a leader in IV iron therapy.
American Regent is committed to US-based manufacturing. To that end, over the last several years we have made significant investments in expanding and modernizing our manufacturing facilities in Ohio and New York. This expansion will nearly double our capacity and allow us to better serve our customers now and in the future.
Speed counts. Flexibility matters. Reliability and quality are paramount. Because patients should never have to wait for the medications they need.
For more information, please visit www.Americanregent.Com.
About Daiichi Sankyo GroupDaiichi Sankyo is dedicated to creating new modalities and innovative medicines by leveraging our world-class science and technology for our purpose "to contribute to the enrichment of quality of life around the world." In addition to our current portfolio of medicines for cancer and cardiovascular disease, Daiichi Sankyo is primarily focused on developing novel therapies for people with cancer as well as other diseases with high unmet medical needs. With more than 100 years of scientific expertise and a presence in more than 20 countries, Daiichi Sankyo and its 16,000 employees around the world draw upon a rich legacy of innovation to realize our 2030 Vision to become an "Innovative Global Healthcare Company Contributing to the Sustainable Development of Society."
For more information, please visit: www.Daiichisankyo.Com.
All trademarks are the property of their respective owners.
Reference: 1. Orange book: Approved drug products with therapeutic equivalence evaluations. US Food & Drug Administration. Accessed September 19, 2023. Https://www.Accessdata.Fda.Gov/scripts/cder/ob/results_product.Cfm?Appl_Type=A&Appl_No=216274#327
PP-PO-US-0008
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SOURCE American Regent, Inc.
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