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8 Acute Pulmonary Embolism
211
Even when patients are compliant with their anticoagulant regimen, treatment
failure may still ensue from other factors that decrease drug levels. Rivaroxaban, for
example, requires administration with the largest meal of the day to ensure adequate
absorption. The site of absorption is also crucial to evaluate for patients requiring
enteral administration of medication due to the inability to ingest orally. The distal
tip of various feeding tubes may terminate in different sites (e.g., stomach, small
intestine), which may drastically impact the absorption of DOACs. For example,
rivaroxaban is mainly absorbed in the stomach and thus will have reduced absorption when it is released distal to the stomach. In contrast, apixaban is absorbed in the
small intestine and the stomach, and potentially in the colon as well [67, 68].
Pharmacists may also consider drug interactions that may lead to DOAC failure
by reviewing the patient’s full medication history. Drug interactions mediated by
CYP-450 or P-glycoprotein transport may decrease the concentration of DOACs.
antiseizure medications such as phenobarbital, phenytoin, and carbamazepine [36].
Uniquely, the use of DOACs with valproic acid or levetiracetam was also associated
with high rates of thromboembolic events, despite no apparent drug interaction
[31, 34].
If pharmacotherapy-related causes of treatment failure have been ruled out,
patients may have other disease states that may contribute to treatment failure. For
example, patients with antiphospholipid antibody syndrome should preferentially
be treated with warfarin over DOACs, as DOACs were associated with an increased
risk of recurrent thrombosis in this population [59]. If patients develop heparininduced thrombocytopenia, the continued use of heparinoids may trigger new
thromboses. Additionally, patients who underwent bariatric surgery may have questionable absorption of DOACS, which may lead to treatment failure. The 2021
ISTH guideline recommended against the use of DOACs in the immediate phase of
post-bariatric surgery [67, 68]. However, strong data for this claim is not available.
In a study involving 102 post-bariatric surgery patients, the recurrence rates of VTE
were 0% and 1.7% while receiving apixaban and rivaroxaban, respectively [62]. If
the above concerns were addressed and the patient does not have any modiable or
identied cause of treatment failure while on an anticoagulant, it may be reasonable
to switch to an alternate agent.
8.7 Conclusion
While anticoagulation remains the cornerstone of PE management, assessment of
patient-specic factors, risk for morbidity and mortality from PE, and risk for bleeding complications informs the decision to utilize systemic thrombolytic therapy,
need for advanced interventional reperfusion procedures, as well as long-term anticoagulant choice and duration of therapy. The pharmacist clinician is a highly qualied member of the healthcare team to lead nuanced discussions on the risks and
benets of anticoagulant and thrombolytic therapies not only at the individual
212
S. K. Kim and L. A. Igneri
patient level, but also through the development of institutional PE treatment pathways and implementation of safety measures. Additionally, pharmacist clinicians
have demonstrated to be a valuable member of the PERT by facilitating thrombolytic and anticoagulation administration and improving the safety and overall care
of patients with PE.
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Chapter 9
Extracorporeal Membrane Oxygenation
StephanieDavis, AlanaCiolek, andAtulDilawri
9.1 ECMO Overview andHistory
Extracorporeal membrane oxygenation (ECMO) is a technique that provides temporary pulmonary and/or cardiac support by offering circulation and perfusion outside of the body [88]. Short-term ECMO was rst used in the 1950s during the rst
open-heart procedure; subsequently, it was used throughout the 1960s in pediatric
respiratory failure and during the repair of congenital heart conditions [88]. In the
1970s, long-term ECMO was successfully utilized for a patient with severe respiratory distress syndrome (ARDS) [88]. It then gained momentum in subsequent years,
particularly with the publication of the CESAR trial, demonstrating positive outcomes 6months after randomization, and then with its successful use during the
H1N1 inuenza epidemic [88, 145].
There are two types of ECMO circuits that consist of several components: cannulas, centrifugal blood pump, tubing, oxygenator, and heat exchanger (see
Fig.9.1a, b) [48]. In short, venovenous ECMO (VV-ECMO) supports the pulmo-
nary system, and venoarterial ECMO (VA-ECMO) provides respiratory and cardiac
support [88]. In VV-ECMO, the circuit is connected in series to the heart and lungs,
and in VA-ECMO, the circuit is connected in parallel [88]. Deoxygenated blood is
removed from the venous system through the inow cannula and then passed
S. Davis (*)
Cardiovascular Surgical ICU and Clinical Nutrition, The Johns Hopkins Hospital,
Baltimore, MD, USA
e-mail: sdavis87@jh.edu
A. Ciolek
New York-Presbyterian Hospital/Weill Cornell Medical Center, New York, NY, USA
A. Dilawri
Cardiothoracic Intensive Care, NewYork-Presbyterian Hospital, Columbia University Irving
Medical Center, New York, NY, USA
Switzerland AG 2025
Y. Alzaidi, M. A. Gebily (eds.), The Pharmacist’s Expanded Role in Critical
Care Medicine, https://doi.org/10.1007/978-3-031-77335-8_9
219© The Author(s), under exclusive license to Springer Nature
Drainage
ry
Oxygenator
ry
a
Cannula
b
Vena cava
Femoral Vein
Pump
Vena cava
Femoral Vein
Aorta
Femoral artery
Oxygenator
Aorta
Femoral artery
Return Cannula
to femoral arte
Drainage
Cannula
Pump
Return Cannula
to femoral arte
Fig. 9.1 VV- and VA-ECMO congurations. (a) Simplied visualization of peripheral VV-ECMO
cannulation. The right femoral vein is cannulated to the inow cannula, which drains to a blood pump
and then to an oxygenator (blood becomes oxygenated as depicted by the red color), and then the
outow cannula drains blood back into the left femoral artery via the outow cannula. (b) Simplied
visualization of peripheral VA-ECMO cannulation. In this gure, the right femoral vein is cannulated
to the inow cannula, which proceeds to a blood pump and oxygenator. Oxygenated blood is returned
to the left femoral artery via the outow cannula [115]. VV-ECMO veno-venous extracorporeal mem-
brane oxygenation, VA-ECMO, venoarterial extracorporeal membrane oxygenation