2019SAN ANTONIO ADVANCED LUNG SYMPOSIUM Disclosure PE ... · Sub‐Massive PE vs Massive PE •Pulmonary Embolism •RV dysfunction •RV/LV >0.9 ... •Multidisciplinary Team approach

PE Response TeamPavan Thangudu, MD

San Antonio Advanced Lung SymposiumDecember 7, 2019

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2 0 1 9 S A N A N T O N I O A D V A N C E D L U N G S Y M P O S I U M

PE Response Team: What is Our Why?Pavan K Thangudu, MD

ICU Co‐Director of Methodist Hospital

Methodist Hospital PERT Team Leader


Disclosure• Nothing to disclose

2 0 1 9 S A N A N T O N I O A D V A N C E D L U N G S Y M P O S I U M 2 0 1 9 S A N A N T O N I O A D V A N C E D L U N G S Y M P O S I U M


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22 M

HR 129

BP: 130/67

SHOCK INDEX < 1

(HR/SBP)

•TroponinI: 0.05•BNP: 494•Lactic:1.9


Anticoagulation Systemic Thrombolysis

ThrombectomyCatheter Directed Thrombolysis

How Should we Proceed?


Surgical Thrombectomy




Sub‐Massive PE vs Massive PE

• Pulmonary Embolism

• RV dysfunction• RV/LV > 0.9

• CT• ECHO

• Elevated tnI• Elevated BNP

• Pulmonary Embolism

•RV failure• SHOCK• Lactic > 2• Vasopressors• Inotropes• SBP < 90• Cardiac Arrest• Syncope


High Risk Pulmonary Emboli

Sub‐Massive

PEHemodynamic Instability

Massive PE

Death

RV DysfunctionMortality of 25%

RV FAILURE

Mortality of 58%

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Sub‐Massive PE

Massive PE Death

Which do we Treat?

The Clot The Right Ventricle




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22 M

HR 129

BP: 130/67

SHOCK INDEX < 1

•TroponinI: 0.05•BNP: 494•Lactic:1.9








Case 1

Patient underwent emergent EKOS

RIJ EKOS approach with 6h dose with concomitant heparin gtt

Bridged to apixaban

Discharged home on room air.

No complications.


1.47

1.090.5

1

1.5

2

Baseline 48 Hour

RV/LV Ratio

Cohort 124% Reduction in RV/LV Ratio

2 (h) EKOS™ Duration | 4/8 mg r‐tPA*

P<0.0001

1.431.09

0.5

1

1.5

2

Baseline 48 Hour

RV/LV Ratio


4 (h) EKOS ™ Duration | 4/8 mg r‐tPA*

P<0.0001

1.49

1.090.5

1

1.5

2

Baseline 48 Hour

RV/LV Ratio



P<0.0001

1.51

1.030.5

1

1.5

2

Baseline 48 Hour

RV/LV Ratio



P<0.0005

Tapson V et al., American Thoracic Society (ATS) meeting, Washington, DC, May 2017.

*Total mg r-tPA: one/two catheters

All OPTALYSE PE cohorts showed significant reduction in RV/LV at 48 hours post‐initiation of procedure

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Optalyse PE

Each of the OPTALYSE two‐, four‐, and six‐hour cohorts reduced RV/LV ratio by 23–26%:

• With tPA doses as low as 4 mgs. per catheter

• With a very low bleeding rate

• Our dose of EKOS varies based off discussion with the intensivist and Interventional Radiologist and varies between 4h – 24h via RIJ approach.




50 MHR 120BP: 164/89O2: 80% on RASHOCK INDEX < 1(HR/SBP)

•Troponin I: 0.14•BNP: 29•Lactic:0.91

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Sub‐Massive


Massive PE

Death


RV FAILURE

Mortality of 58%


Sub‐Massive PE

Massive PE Death

Which do we Treat?



WHY DOES MASSIVE PE KILL PATIENTS?


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Sub‐Massive PE

Massive PE Death

Which do we Treat?



50 MHR 120BP: 164/89O2: 80% on RASHOCK INDEX < 1(HR/SBP)



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AnticoagulationSystemic

Thrombolysis


210‐575‐PERTMechanical Circulatory Support



Systemic Thrombolysis VA ECMO

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tPA FAILS


tPA kills

60% 15%

8%


EKOS won’t work


EKOS EKOS

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Previous investigations have estimated that about 50% of patients with massive PE died within 30 min, 70% within an hour and >85% died within 6 h from the symptom's onset [17].



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VAECMO


• Right Ventricle Unloading• Fibrinolytic• Provides oxygenation support• Minimizes need for vasopressors and inotropes

• Minimizes need for Mechanical Ventilation

VAECMO




Sub‐Massive


Massive PE

Death


RV FAILURE

Mortality of 58%

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Sub‐Massive PE

Massive PE Death

Which do we Treat?





50 MHR 120BP: 164/89O2: 80% on RASHOCK INDEX < 1


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tpA VA ECMO


Case 2 ABGs

post intubation 7.235 | 56 |50.4 on PRVC 24 | 450 |100% |5 O2 sat of 77%

While bagging patient: 7.338 | 35.2 | 48.2 with O2 sat of 81%

s/p 50mg tpA – 7.242 | 58.2 | 64 on PRVC 24 | 450 |100% |5 O2sat of 87%


Methodist PERT Structure

Referring Physician

Critical Care Team

Radiology

Cardiology MCS team Hospitalist

Administration

Patient Placement

NursingPharmacy

Marketing

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Benefits of PERT

• Multidisciplinary Team approach to a complex treatment.

• Immediate response with protocolized care.

• Quarterly Meetings to discuss cases and thresholds

• Some data to indicate reduce length of ICU stay

• Less variation in treatment

• Follow up management with PERT clinic


Our Outcomes

• Launched April 15, 2019

• 105 activations

• 14 Massive PE –• 11 VA ECMO activations, 8 cannulations (1 septic pulmonary emboli)

• ~30% EKOS for Sub‐massive PE.

• 6 IVC filters

• 4 complicated anticoagulation strategies

• 4 Septic Pulmonary Emboli


Methodist PERT Algorithm

+PE diagnosis

210‐575‐PERT

YES NO

Sub‐massive PE

appropriate for EKOS?

Intensivist places EKOS order 1,2

Pt to go to MSICU unless on advanced cardiac device

NO

Assess for home

management4

No

Call 210‐575‐ECMO

Yes

ECMO therapy + Heparin gtt –NO LYTICS

Systemic tpA3

Yes

Sub‐massive PE Criteria for EKOS• clot within first or second branch of

pulmonary artery• RV dysfunction on ECHO • RV/LV ratio > 0.9 on CT or ECHO• ctnI > 0.5 pg/mL• BNP > 90 pg/mL

Is PE Massive? SBP < 90, SaO2 < 90%Vasopressors, Cardiac

arrest, Syncope Bradycardia, Lactate > 2, Syncope,

Shock Index >1


IS THE PE MASSIVE?

• SHOCK INDEX > 1

• SBP < 90

• LACTATE > 2

• SYNCOPE

• Cardiac Arrest

• Vasopressors/Inotropes

• SaO2 < 90% or INCREASING OXYGEN REQUIREMENT


• 58 W

• SYNCOPE x4

• HR 106/ BP 106

• SHOCK INDEX = 1

• Temp 94.7

• Cool Extremities

• Platelets 124

• Bicarb 20

• Cr 1.29

• Lactate 4

• BNP 308

• Troponin 0.27


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Sub‐Massive


Massive PE

Death


RV FAILURE

Mortality of 58%


Sub‐Massive PE

Massive PE Death

Which do we Treat?



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AnticoagulationSystemic

Thrombolysis


210‐575‐PERTMechanical Circulatory Support



• 58 W

• SYNCOPE x4

• HR 106/ BP 106

• SHOCK INDEX = 1

• Temp 94.7

• Cool Extremities

• Platelets 124

• Bicarb 20

• Cr 1.29

• Lactate 4

• BNP 308

• Troponin 0.27


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Previous investigations have estimated that about 50% of patients with massive PE died within 30 min, 70% within an hour and>85% died within 6 h from the symptom's onset [17].


VAECMO


• Right Ventricle Unloading• Fibrinolytic• Provides oxygenation support• Minimizes need for vasopressors and inotropes

• Minimizes need for Mechanical Ventilation

VAECMO


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WHICH MORTALITY RATE would you offer your

patient?60% or 5% Please call

210‐575‐PERT


© 2017 Methodist Healthcare. Confidential: Contains proprietary information. Not intended for external distribution.



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Documents

2019SAN ANTONIO ADVANCED LUNG SYMPOSIUM Disclosure PE ... · Sub‐Massive PE vs Massive PE •Pulmonary Embolism •RV dysfunction •RV/LV >0.9 ... •Multidisciplinary Team approach