Faculty Bibliography

Objective: Pulmonary embolism response teams (PERTs)have become increasingly popular at institutions around the country, although only anecdotal evidence is available to support their efficacy. PERTs are mechanisms for rapid involvement of a multidisciplinary team in the management of a time-sensitive condition with many treatment options spanning multiple specialties. We aimed to evaluate time to management of pulmonary embolisms and outcomes since 2016 under our institution's PERT. Method(s): We retrospectively reviewed 151 patients with PERT activations since inception, collecting data on demographics, time to treatment, treatment modality, and in-hospital outcomes. Result(s): The average age was 62.4 years (range, 30-95 years), and 54% of patients were male; 39.4% of patients had normal echocardiographic recordings, with 27% showing right ventricular (RV)hypokinesis, 9.1% showing elevated pulmonary artery pressures, and 6.1% showing RV enlargement. Anticoagulation alone was received by 91.4% of patients; 4.5% had catheter-directed therapy (CDL), and 3.0% had systemic administration of tissue plasminogen activator (tPA). The average time to invasive intervention was 665 minutes (95% confidence interval [CI], 249-1080 minutes)for CDL and 22 minutes (95% CI, 0-456 minutes)for systemic tPA. Average time to anticoagulation was 3 minutes (95% CI, 154-160 minutes). For patients with echocardiographic findings suggestive of RV strain, 21.4% (95% CI, 0.04-0.51)had tPA or an invasive intervention. Of patients with echocardiographic findings consistent with RV strain who underwent conservative management, 80% were discharged home after an average length of stay of 6.0 days (95% CI, 4.5-7.5). Twenty (14.1%; 95% CI, 5.5-22.5)patients receiving anticoagulation alone had bleeding events, whereas none of the patients undergoing CDL or tPA had bleeding. Sixteen (11.2%; 95% CI, 5.7-16.3)patients who had anticoagulation died in the hospital or were discharged to hospice, and none of the patients receiving CDL or tPA died or were discharged to hospice. The odds of in-hospital death were lower for patients receiving anticoagulation than for those without (odds ratio, 0.29), suggesting appropriate identification of high-risk patients. Average hospital stay was 6.5 days (95% CI, 4.9-8.5)for patients who received anticoagulation, 5.3 days for CDL (95% CI, 0-11.2), and 8 days for tPA (95% CI, 2.6-13.4). Conclusion(s): We found that a dedicated PERT team leads to efficient delivery of care and excellent outcomes. The majority of pulmonary embolisms can be managed with anticoagulation alone. CDT and systemic tPA are safe adjunctive treatments for select patients.

Background Clinical investigations of shock in cardiac intensive care units (CICUs) have primarily focused on acute myocardial infarction (AMI) complicated by cardiogenic shock (AMICS). Few studies have evaluated the full spectrum of shock in contemporary CICUs. Methods and Results The Critical Care Cardiology Trials Network is a multicenter network of advanced CICUs in North America. Anytime between September 2017 and September 2018, each center (n=16) contributed a 2-month snap-shot of all consecutive medical admissions to the CICU. Data were submitted to the central coordinating center (TIMI Study Group, Boston, MA). Shock was defined as sustained systolic blood pressure <90 mm Hg with end-organ dysfunction ascribed to the hypotension. Shock type was classified by site investigators as cardiogenic, distributive, hypovolemic, or mixed. Among 3049 CICU admissions, 677 (22%) met clinical criteria for shock. Shock type was varied, with 66% assessed as cardiogenic shock (CS), 7% as distributive, 3% as hypovolemic, 20% as mixed, and 4% as unknown. Among patients with CS (n=450), 30% had AMICS, 18% had ischemic cardiomyopathy without AMI, 28% had nonischemic cardiomyopathy, and 17% had a cardiac cause other than primary myocardial dysfunction. Patients with mixed shock had cardiovascular comorbidities similar to patients with CS. The median CICU stay was 4.0 days (interquartile range [IQR], 2.5-8.1 days) for AMICS, 4.3 days (IQR, 2.1-8.5 days) for CS not related to AMI, and 5.8 days (IQR, 2.9-10.0 days) for mixed shock versus 1.9 days (IQR, 1.0-3.6) for patients without shock ( P<0.01 for each). Median Sequential Organ Failure Assessment scores were higher in patients with mixed shock (10; IQR, 6-13) versus AMICS (8; IQR, 5-11) or CS without AMI (7; IQR, 5-11; each P<0.01). In-hospital mortality rates were 36% (95% CI, 28%-45%), 31% (95% CI, 26%-36%), and 39% (95% CI, 31%-48%) in AMICS, CS without AMI, and mixed shock, respectively. Conclusions The epidemiology of shock in contemporary advanced CICUs is varied, and AMICS now represents less than one-third of all CS. Despite advanced therapies, mortality in CS and mixed shock remains high. Investigation of management strategies and new therapies to treat shock in the CICU should take this epidemiology into account.

OBJECTIVES/OBJECTIVE:To characterise the variation in composition, leadership, and activation criteria of rapid response and cardiac arrest teams in five north-eastern states of the USA. DESIGN/METHODS:Cross-sectional study consisting of a voluntary 46-question survey of acute care hospitals in north-eastern USA. SETTING/METHODS:Acute care hospitals in New York, New Jersey, Rhode Island, Vermont, and Pennsylvania. PARTICIPANTS/METHODS:Surveys were completed by any member of the rapid response team (RRT) with a working knowledge of team composition and function. Participants were all Medicare-participating acute care hospitals, including teaching and community hospitals as well as hospitals from rural, urban and suburban areas. RESULTS:Out of 378 hospitals, contacts were identified for 303, and 107 surveys were completed. All but two hospitals had an RRT, 70% of which changed members daily. The most common activation criteria were clinical concern (95%), single vital sign abnormalities (77%) and early warning score (59%). Eighty one per cent of hospitals had a dedicated cardiac arrest team.RRT composition varied widely, with respiratory therapists, critical care nurses, physicians and nurse managers being the most likely to attend (89%, 78%, 64% and 51%, respectively). Consistent presence of critical care physicians was uncommon and both cardiac arrest teams and teams were frequently led by trainee physicians, often without senior supervision. CONCLUSIONS:As the largest study to date in the USA, we have demonstrated wide heterogeneity, rapid team turnover and a lack of senior supervision of RRT and cardiac arrest teams. These factors likely contribute to the mixed results seen in studies of RRTs.

Keywords: pulmonary embolism; submassive; survey.

Pulmonary embolism (PE) is a leading cause of morbidity and mortality worldwide. PE is a complex disease with a highly variable presentation and the available treatment options for PE are expanding rapidly. Anticoagulation (AC), systemic lysis, surgery, and catheter-directed thrombolysis (CDT) play important roles in treating patients with PE. Thus, a multidisciplinary approach to diagnosis, risk stratification, and therapy is required to determine which treatment option is best for a given patient with this complex disease.

Pulmonary embolism (PE) is a common and potentially deadly form of venous thromboembolic disease. It is the third most common cause of cardiovascular death and is associated with multiple inherited and acquired risk factors as well as advanced age. The prognosis from PE depends on the degree of obstruction and hemodynamic effects of PE and understanding the pathophysiology helps in risk-stratifying patients and determining treatment. Though the natural history of thrombus is resolution, a subset of patients have chronic residual thrombus, contributing to the post-PE syndrome.

Pulmonary embolism (PE) is a potentially fatal disease with a broad range of treatment options that spans multiple specialties. The rapid evolution and expansion of novel therapies to treat PE make it a disease process that is well suited to a multidisciplinary approach. In order to facilitate a rapid, robust response to the diagnosis of PE, some hospitals have established multidisciplinary pulmonary embolism response teams (PERTs). The PERT model is based on existing multidisciplinary teams such as heart teams and rapid response teams. A PERT is composed of clinicians from the range of specialties involved in the treatment of PE, including pulmonology critical care, interventional radiology, cardiology, and cardiothoracic surgery among others. A PERT is a 24/7 consult service that is able to provide expert advice on the initial management of PE patients and convene in real time to develop a consensus treatment plan specifically tailored to the needs of a particular patient and consistent with the capabilities of the institution. In this review, we discuss the rationale for establishing a PERT and its potential benefits. We discuss considerations in forming a PERT and present case studies of several PERTs currently in operation at different institutions. We also discuss potential difficulties in forming a PERT and review evidence that has been generated by some of the PERTs that have been in operation the longest.

Pulmonary Embolism Response Teams (PERTs) have emerged to provide rapid multidisciplinary assessment and treatment of PE patients. However, descriptive institutional experience and preliminary outcomes data from such teams are sparse. PERT activations were identified through a retrospective review. Only confirmed submassive or massive PEs were included in the data analysis. In addition to baseline variables, the therapeutic intervention, length of stay (LOS), in-hospital mortality, and bleeding rate/severity were recorded. A total of 124 PERT activations occurred over 20 months: 43 in the first 10 months and 81 in the next 10. A total of 87 submassive (90.8%) and massive (9.2%) PE patients were included. The median age was 65 (51-75 IQR) years. Catheter-directed thrombolysis (CDT) was administered to 25 patients, systemic thrombolysis (ST) to six, and anticoagulation alone (AC) to 54. The median ICU stay and overall LOS were 6 (3-10 IQR) and 7 (4-14 IQR) days, respectively, with no association with any variables except a brain natriuretic peptide (BNP) >100 pg/mL ( p=0.008 ICU LOS; p=0.047 overall LOS). Twelve patients (13.7%) died in the hospital, nine of whom had metastatic or brain cancer, with a median overall LOS of 13 (11-17 IQR) days. There were five major bleeds: one in the CDT group, one in the ST group, and three in the AC group. Overall, (1) PERT activations increased after the first 10 months; (2) BNP >100 pg/mL was associated with a longer LOS; (3) rates of mortality and bleeding did not correlate with treatment; and (4) the majority of in-hospital deaths occurred in patients with advanced cancer.

Management of high-risk pulmonary embolism (PE) requires an understanding of the pathophysiology of PE, options for rapid clot reduction, critical care interventions, and advanced cardiopulmonary support. PE can lead to rapid respiratory and hemodynamic collapse via a complex sequence of events leading to acute right ventricular failure. Importantly, reduction in pulmonary vascular resistance must be accomplished either by systemic thrombolytics, catheter directed thrombolytics, endovascular clot extraction, or surgical embolectomy. There are important advances in these techniques all of which have a niche role in the cardiopulmonary stabilization of critically ill patient with PE. Critical care support surrounding the above interventions is necessary. Maintenance of systemic perfusion and cardiac output may require careful titration of vasopressors, inotropes, and preload. Extreme caution should be taken with approach to intubation and positive pressure ventilation. A hemodynamically neutral induction with preparations for circulatory collapse should be the goal. Once intubated, the effect of positive pressure on pulmonary vascular resistance and right ventricular hemodynamics is necessary. Veno-arterial extra corporeal membrane oxygenation plays an increasingly important role in the stabilization of the hemodynamically collapsed patient who either has a contraindication to systemic lytics, failed systemic lytics, or requires a bridge to surgical or catheter embolectomy. Veno-arterial extra corporeal membrane oxygenation has also been used alone to stabilize the circulation until hemodynamics normalize on anticoagulation and has also been used in tenuous patient as a safety net for endovascular procedures.