(1257) Role for Intravenous Fluid Challenge for Emergent Circulatory Support in Acute Pulmonary Embolism

Introduction: In acute pulmonary embolism (PE), early resuscitation is crucial in preventing right ventricular failure. An intravenous fluid (IVF) challenge is commonly used as an initial intervention to address hypotension. The decision to administer fluids centers on finding the delicate balance between early optimization of RV performance and reducing the risk of perpetuating RV dilation and precipitating RV failure. Guidelines recommend considering a low-volume fluid challenge. However, there is a paucity of related data, with small sample size in a single human study that supports fluid loading, and conflicting hemodynamic findings in animal studies.

Description: We present three cases of critically ill patients with acute PE admitted to our hospital. All were Caucasian males ranging in age from 52-66 years without prior history of cardiopulmonary disease or cancer. Two patients presented with syncope; one with dyspnea. On presentation, vital signs included HR 117-141 bpm and SBP 80-103 mmHg, and biomarkers were elevated (troponin T 0.079-0.11 ng/mL, NT-proBNP 1312-3655 pg/mL, and lactate 5.2-8.6 mmol/L ). Their PESI and BOVA scores were 96-134 and 5. They had large clot burdens involving proximal and distal pulmonary arteries bilaterally and in the legs. Additionally, on echocardiogram, they had severely dilated right ventricles with reduced function (TAPSE 0.8-1.38 cm and TAPSE/RVSP 0.17-0.65) and estimated RVSP 47-63 mmHg. They were deemed to be volume depleted and resuscitated with 0.5- 3.5 liters of isotonic fluids. All were anticoagulated with unfractionated heparin. At 24 and 48 hours lactate had improved to 1.4-2.4 and 0.9-1.5 mmol/L. Each patient ultimately achieved full recovery without hemodynamic instability or the need for advanced reperfusion therapy. Hospital length of stay ranged from 3 to 10 days and all discharged to home.

Discussion: This small case series supports an ongoing role of IVF for initial resuscitation in acute PE with clinical hypovolemia. While clinical experience suggests judicious IVF resuscitation with close follow-up through multimodal volume assessment and a low threshold to initiate vasopressors for refractory hypotension, how best to determine the appropriateness for IVF resuscitation and monitor RV response remains unclear and further research is needed.