Vancouver General Hospital Pulmonary Embolism Response Team (VGH PERT): Initial 3-year Experience in the Multidisciplinary Care of Patients with Massive and Submassive Pulmonary Embolism
CCCF ePoster library. Romano K. 11/13/19; 283363; EP126
Dr. Kali Romano
Dr. Kali Romano
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Abstract
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ePoster
Topic: Retrospective or Prospective Cohort Study or Case Series

Romano, Kali1,2 ; Cory, Julia1 ; Ronco, Juan2; Bone, Jeff3; Finlayson, Gordon1,2
1Department of Anesthesiology, Pharmacology and Therapeutics, UBC, Vancouver, Canada;
2Department of Critical Care Medicine, UBC, Vancouver, Canada;
 3Department of OBGYN, UBC, Vancouver, Canada
 


Introduction:
Increasingly recognized is the clinical challenge and lack of consensus in managing patients presenting with acute pulmonary embolism (PE).(2) Treatment options intersect several medical, surgical, and perioperative specialties, demanding urgent and coordinated management. Inspired by existing models (3–5) we created an institutional Pulmonary Embolism Response Team (PERT) to improve the care of patients with submassive/massive PE.
 
Objectives: To report our initial 3 year experience and outcomes of patients presenting to our institution with high risk PE and managed using the VGH PERT protocol.
 
Methods:
All PERT activations were identified based on pre-established activation criteria and followed a pre-establish algorithm for assessment (Figure 1). Radiologically confirmed PE meeting activation criteria, and patients presenting in shock or cardiac arrest with echocardiographic evidence of pulmonary embolism were including in the data analysis. PE risk categories were defined using ESC guideline criteria (1) with adopted AHA nomenclature (6) to facilitate clinical communication with North American standards (Table 1). In addition to baseline clinical variables, therapeutic interventions, major bleeding events defined by ISTH guidelines (7) and 3 month mortality were recorded in HIPAA-compliant web based application REDCap. Data was analyzed in Excel and R (version 3.5.3).
 
Results:
A total of 128 activations occurred over 3 years: 36 in the first, 45 in the second, and 47 in the third year. The median age of patients was 64 (53-73 IQR) years. The majority (78%) of activations originated from the emergency department. 111 (87%) patients presented with submassive PE, 69 (54%) of which were in the submassive-high risk group, while 14 (11%) presented with massive PE. Advanced reperfusion therapy was used in 29 (23%) patients overall, 18 (26%) with submassive-high risk PE, and 11 (79%) with massive PE. Catheter directed thrombolysis was used in 25 of 29 cases of advanced reperfusion therapy. Of 12 (9%) mortalities, 2 received advanced reperfusion therapy with only 1 death attributable to non-survivable intracranial hemorrhage following catheter directed therapy for submassive high-risk PE. There were 10 (8%) major bleeding events, 8 of which occurred in patients receiving advanced reperfusion therapy. (Table 2)
 
Conclusions:
To our knowledge we report the first Canadian experience using a pre-established protocol and PERT. The majority of our PERT activations arise from the emergency department for submassive high-risk PE. Our institutional use of advanced reperfusion therapy was notably higher than reported in registry literature ( 23% vs 9-13%) (8), with an associated risk of major bleeding events but not mortality.   
 


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1. Konstantinides SV, Torbicki A, Agnelli G, Danchin N, Fitzmaurice D, Galiè N, et al. 2014 ESC guidelines on the diagnosis and management of acute pulmonary embolism. Eur Heart J. 2014 Nov 14;35(43):3033–69, 3069a–3069k.
2. Secemsky E, Chang Y, Jain CC, Beckman JA, Giri J, Jaff MR, et al. Contemporary Management and Outcomes of Patients with Massive and Submassive Pulmonary Embolism. Am J Med. 2018 Dec;131(12):1506-1514.e0.
3. Kabrhel C, Rosovsky R, Channick R, Jaff MR, Weinberg I, Sundt T, et al. 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. Chest. 2016 Aug;150(2):384–93.
4. Dudzinski DM, Piazza G. Multidisciplinary Pulmonary Embolism Response Teams. Circulation. 2016 Jan 5;133(1):98–103.
5. Provias T, Dudzinski DM, Jaff MR, Rosenfield K, Channick R, Baker J, et al. The Massachusetts General Hospital Pulmonary Embolism Response Team (MGH PERT): Creation of a Multidisciplinary Program to Improve Care of Patients With Massive and Submassive Pulmonary Embolism. Hosp Pract. 2014 Feb 1;42(1):31–7.
6. Jaff MR, McMurtry MS, Archer SL, Cushman M, Goldenberg N, Goldhaber SZ, et al. Management of Massive and Submassive Pulmonary Embolism, Iliofemoral Deep Vein Thrombosis, and Chronic Thromboembolic Pulmonary Hypertension. Circulation. 2011 Apr 26;123(16):1788–830.
7. Kaatz S, Ahmad D, Spyropoulos AC, Schulman S. Definition of clinically relevant non-major bleeding in studies of anticoagulants in atrial fibrillation and venous thromboembolic disease in non-surgical patients: communication from the SSC of the ISTH. J Thromb Haemost. 2015;13(11):2119–26.
8. Pollack CV, Schreiber D, Goldhaber SZ, Slattery D, Fanikos J, O'Neil BJ, et al. Clinical Characteristics, Management, and Outcomes of Patients Diagnosed With Acute Pulmonary Embolism in the Emergency DepartmentInitial Report of EMPEROR (Multicenter Emergency Medicine Pulmonary Embolism in the Real World Registry). J Am Coll Cardiol. 2011 Feb 8;57(6):700–6.
 
 

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