How and Why to Form a PERT, Pulmonary Embolism Response Team

Transcription

1 Disclosures How and Why to Form a PERT, Pulmonary Embolism Response Team Rachel P. Rosovsky, MD, MPH No disclosures Rachel P. Rosovsky, MD, MPH April 21, 2017 AC Forum Agenda Pulmonary Embolism Scope of the problem Treatment options Pulmonary Embolism Response Team (PERT) Description Multidisciplinary follow up clinic Research: Advancing the science of PE care National PERT Consortium Case 48 year old male presents to local hospital with acute SOB. CTA showed extensive bilateral PE and RV/LV ratio >1. Given one dose lovenox and sent to MGH. At MGH: Vitals: 87% on room air, initially required 15 L NC oxygen, HR 150, RR 28, BP 140/79. ECHO: RV dilated, hypokinetic, septal flattening, RVSP 54 mm Hg Elevated troponin and BNP SOB = shortness of breath RV/LV: right ventricle/left ventricle MGH = Massachusetts General Hospital 3 4 Case Why worry about Pulmonary Embolism? What would you do? Scope of the Problem A. Unfractionated heparin and observe B. Systemic thrombolysis with 100 mg tpa C. Surgery D. Catheter directed thrombolysis E. Catheter thrombectomy of PE 5 6 1

2 Venous Thromboembolism: The Third Leading Cause of Cardiovascular Death VTE is Common DVT 2 Million Post-thrombotic Syndrome 800,000 PE 600,000 Deaths 60,000 Silent PE 1 Million Pulmonary Hypertension 30,000 Estimated Cost of VTE Care $1.5 Billion/year Hirsh J and Hoak J. American Heart Association Heit J et al. Blood. 2005;106: Abstract 910. Anderson FA et al. Am J Hematol. 2007;82: Am J Hematol Feb;86(2): Why worry about Pulmonary Embolus? Pathophysiology of Pulmonary Embolism Fatal within 1 h after the onset of symptoms in 10% of cases Untreated PE mortality rate ~30% Early mortality is closely linked to the probability of recurrent PE Recurrent PE mortality: ~25% 9 10 Abrahams van-doorn P. and Hartmann IJC. Imaging Insights. 2011; 2: Eur Heart J Nov 14;35(43): , 3069a-3069k Most Patients with PE do Well, but some do not PE Mortality (ICOPER) 52.4%* 15% *62.5% from recurrent PE 11 Becattini C, Agnelli G. Predictors of mortality from pulmonary embolism and their influence on clinical management. Thromb Haemost. 2008; 100(5): Abrahams van-doorn P. and Hartmann IJC. Imaging Insights. 2011; 2: Dalen JE. Chest. 2002; 122: Kucher et al Massive PE Circulation

3 Therapeutic Alternatives in Acute Venous Thromboembolism Pulmonary Embolism: Treatment Options Anticoagulation Unfractionated Heparin Continuous Intravenous Full-Dose Subcutaneous Low-Molecular-Weight Heparin Direct Thrombin Inhibitors Synthetic Pentasaccharide Xa Antagonist Warfarin New oral Factor Xa inhibitors Thrombolytic Therapy Systemic Catheter Directed Pharmacomechanical Catheter-Directed Thrombolysis (PCDT) Mechanical Thromboaspiration Surgical Thrombectomy Adjunctive Therapy Vena Caval Filter Extracorporeal support Guidance in the Literature for Treatment of Massive/Submassive PE: Very Little Acute Massive/Submassive PE Therapy Who warrants more aggressive therapy? 15 Circulation 2011;123: European Heart Journal (2014) 35, Circulation 2011;123: Guidance in the Literature for Treatment of Massive/Submassive PE: Very Little Thrombolysis: Do patients with submassive PE benefit? The Controversy Continues No randomized trials or observational studies have compared contemporary CDT with systemic thrombolytic therapy. Recent Trials Full dose systemic lysis PEITHO TOPCOAT Reduced dose lysis MOPPET: half dose systemic lysis ULTIMA, SEATTLE II: ultrasound enhanced lysis 17 CHEST 2016; 149(2):

4 EKOS Thrombolysis (EndoWave Infusion Catheter System) Suction Embolectomy (VORTEX) Ultrasonic pressure waves emitted along the catheter Lower drug dose (10-24 mg rt-pa) delivered at 1-2 mg/hour Rapid removal of clot Less invasive than surgery, with few complications No large case series Resource intensive Surgery Revisited ECMO: An option in PE Care Biocompatible Tubes Centrifugal Pumps Small, efficient oxygenators 47 patients undergoing acute embolectomy over 5 year period 26% in cardiogenic shock, 11% in cardiac arrest 3 intraoperative deaths, 2/3 in cardiac arrest Leacche et al. J Thoracic and Cardiovasc Surgery 2005; 129: Current use of ECMO for PE Keep people alive on cardiopulmonary bypass outside OR. Immediate support for PE patients in shock Lots of options: how decide, who decides? Postop support for RV failure after surgical embolectomy Peri-procedural support for suction embolectomy Preop support of patients that have received lytic therapy ECMO: extracorporeal membrane oxygenation

5 Pulmonary Embolism: Which therapy to use? Pulmonary Embolism Response Team (PERT) Best treatment unknown - no standard approach MGH example - strategies all over the map Varies by medical service, location, size and threat to patient, etc. etc. No consistency in decision-making No single team or clearing-house No accepted algorithm No centralized location for care No systematic evaluation of results ED / ICU / Floor Team Pulmonary, Hematology Vascular Medicine/Cardiology Cardiac Surgery Pulmonary Embolism Response Team (PERT) Description of the Pulmonary Embolism Response Team Objectives Respond expeditiously to treat patients with massive and submassive PE Provide best therapeutic options available for each patient Leverage the input of a multidisciplinary team of experts Coordinate care among services involved in care of PE Develop protocols for the full range of therapies available Collect data on clinical presentation, treatment efficacy, and outcomes (short and long-term) PERT Program Flow Map PERT Activation Expeditious input and clinical judgment from multiple specialties to optimize therapy ED MGH floor OSH PERT fellow: History Physical Labs EKG Echo CT-PE Low Risk Submassive Massive ACTIVATE PERT MULTIDISCIPLIARY TEAM Electronic Meeting Vascular Medicine Cardiac Surgery ICU/Pulmonary Hematology Emergency Medicine Rad, Echo On Discharge: Multidisciplinary Follow-Up Clinic A/C Lytic CDT Aspiration ECMO Surgery One telephone number for internal use Answered 24/7 by the MASCO answering service Follows documented protocol Fellow receives page that includes a pre-defined set of relevant information Administrator simultaneously receives the same information via

6 PERT Activation Multidisciplinary Collaboration Multidisciplinary Virtual Consultation Leverages low- and no-cost internal and commercially available tools Web-based HD videoconferencing Group distribution lists Group paging Hematology/ Oncology Cardiology Emergency Medicine Vascular Medicine and Intervention PERT Pulmonary/ Critical Care Cardiac Surgery Cardiac and Thoracic Imaging Echocardiography Nursing Research Quality & Safety PERT Multidisciplinary Follow Up Clinic PERT Multidisciplinary Follow Up Clinic Structure Participants: All PERT members are invited to attend pre conference and clinic as observer or participant Disciplines represented: Vascular Medicine and Intervention, Pulmonary and Critical Care, Hematology, Emergency Medicine, Cardiothoracic Surgery, and Radiology Timing to follow up: 4 to 6 weeks after the PE PERT Database PERT Research: Advancing the Science of PE Care Web-based, REDCap HIPAA compliant 16 forms Up to 347 variables Prospective data entry Follow for a year 794 Patients, October 2012 through February

7 PERT Data: Activations A Multidisciplinary Pulmonary Embolism Response Team : Initial 30-Month Experience With a Novel Approach to Delivery of Care to Patients With Submassive and Massive Pulmonary Embolism. As soon as PERT launched Immediate response Kabrhel C, Rosovsky R, Channick R, et al. Chest 2016; 150:384 Virtual consult Average length = 25 mins. Range = 5-15 physicians Off hours/weekends = 53% Kabrhel, Rosovsky et al. Chest PERT Data: Categories of PE PERT Data: Mortality Mix of PE evolved over time Majority are severe Increase in low risk Massive PE mortality 25% Lower than National average of 52% Does our approach improve outcomes? 52.4%* 15% 39 Kabrhel, Rosovsky et al. Chest Kabrhel, Rosovsky et al. Chest National PERT TM Consortium Expanding PERT Nationally and Internationally Launched May committees Governance: established 501c3 Education Slide/article library, webinar, PERTintent updates, mentorship program, awareness programs Communication Website, tweet, facebook Clinical practice and protocols Algorithms Research Pilot study of database with 14 sites Development

8 Important Consideration in Creating a PERT 43 How to create a PERT 44 Structure Physician lead vs steering committee? Which sub specialties? Business Plan What data do you have to support PERT. Who will fund? Join National Consortium? Administrative Support: What is available at your institution? Organization How will your PERT be organized? Call schedule, logistics, availability, billing Follow up Who, where, what to be performed? age specific cancer related screening, IVC filter removal, CTEPH Research PERT: Closing Reflections Paradigm Shift In real time. Immediately and simultaneously engages multiple experts to determine best course of action. Multidisciplinary PERT members, outside hospital, other specialists Patient and family members Importance of follow up PERT National Consortium: governance, education, clinical, research, communication How to create a PERT Thank you