PERT symposium lectures (2/11/2022)
Fibrinolysis-risks-and-contraindications
Outline of the workflow for PERT Activation:
General Overview
PERT Activations
When you receive a PERT activation, these usually fall into one of three categories.
- Please document your pert activation using the .PERT smart phrase, and use the note type “Significant Event” so that this data may be easily found by our research team.
- Remember to offer appropriate risk stratification at the time of activation based on available data.
- Low risk PE- sPESI 0 with no evidence of troponin leak, EKG strain pattern or CT/Echo evidence of RV strain.
- Low risk Intermediate PE- sPESI 1 or greater, these patients can have either a troponin leak or imaging evidence of strain but not both, see below
- High risk intermediate PE- sPESI 1 or greater, with Troponin leak and imaging evidence of strain, but with systolic BP >90 mmHg
- High risk (massive) PE- any PE with systolic BP <90 mmHg (or marked decrease from baseline with evident hypoperfusion) for more than 15 minutes, not readily explainable by distributive of Left sided cardiogenic shock.
Calls off hours (after 4 pm and weekends) should be handled as follows (updated August 11, 2022)
- Low risk PE- these are usually for decision support when anticoagulation cannot be used, or from someone who hasn’t read the algorithm. Can document recommendations as usual. If the question is regarding safe ER discharge home, refer the ER team to their recently released protocol for that.
- Low risk intermediate- Document in the pert note, typically no intervention is needed, and send a message to Reem Ismail
- High risk intermediate- Contact PH on call, not the interventionalist. The PH team will handle the rest in terms of whether procedures are needed overnight and clinical trial screening, and help suggest disposition. Based on conversation with PH on call, document PERT note. Recommend consult to PH and send a message to PH staff
- Massive PE- If there are no contraindications to full dose lytics in a decompensating patient, can offer decision support if requested without delay. If contraindicated or if pseudostable on a low dose of pressors, discuss with PH on call to assess for interventional procedures.
PERT Documentation and Sign Out
- Please make sure your diagnosis of PE severity is accurate based on the data you have available, and the checkbox matches the narrative assessment and plan.
- It is helpful to our data abstractor to document the note type as “SIGNIFICANT EVENT”. Just as important, the PH team needs to know about off hours activations, and recommending a PH consult alone does not always translate to that getting done by the primary team.
- The PH team determined the best way to make sure the patients are on our radar for definitive management would be to at least add the patient to the “DET PULM HYPERTENSION CONSULTS TEAM” on the add team function on epic, feel free to email or epic message to the pulmonary hypertension staff on call to make sure any overnight or weekend/holiday calls get back to the PH team.
PERT consultations from outside HFH-Detroit
- Outside hospitals: we are not be able to offer multidisciplinary recommendations (cannot see imaging); as such, the patient would need to be transferred to HFH-Detroit for an evaluation.
- If ATMO calls because someone is wondering if they should transfer, this should be left to best clinical judgement based on the available data.
- If ATMO calls because someone is going to be transferring in, it can be helpful to know the circumstances and ETA so that we can prepare if procedures are needed.
- Henry Ford Fairlane: This is a satellite of HF Main’s ER with preferential admitting in Detroit. They can activate HFH-Detroit PERT when patient’s satisfy criteria for activation,
- Other ER’s similar include: Sterling Heights, Cottage, and Plymouth
- In satellite ER’s, (Fairlane, Sterling Heights, Cottage and Plymouth) PERT activation should be carried out as if the patient were in HFH-Detroit ER. If there is a question on disposition to telemetry versus ICU pending a procedure, then the interventionalist should be contacted to discuss the urgency/need for procedure during the day. If after hours/weekends/overnight, the on call PH staff can help with that.
STAT versus Routine Echoes
Once a high risk intermediate or massive PE is determined to be in need of a procedure based on hemodynamic, RV strain biomarker and CT evidence, the utility of an echo would be to rule out intracardiac thrombus prior to catheter insertion. This can be accomplished by bedside echo. If more technical expertise is needed, STAT echo can be requested, this would suggest that a procedure is imminent for a relatively sick patient and the proceduralist is aware of the case. Please note that a STAT echo is done by the in-house Cardiology fellow taking care of the entire CICU and the images need to be reviewed with their staff on home call, and some diagnostic stewardship is needed here. For routine echoes, if a procedure is needed during the day please let the PH team know as we can help prioritize and expedite scheduling with the echo lab.
HI-PEITHO and other research
Our site is online for the HI-PEITHO trial. As a background the original PEITHO trial was published in 2012 looking at thrombolytic versus standard anticoagulation in intermediate risk PE. This new study will determine benefit or lack thereof for EKOS in High Risk Intermediate PE versus standard anticoagulation alone. Further details will be shared on basic inclusion/exclusion and we have a few kinks to iron out in terms of meeting the time from screening to randomization but I wanted to put this on your radar as we just randomized our first patient today!
Additionally, as you can see from the PERT note template, the activations are tracked for data extraction. From May 2017 to the present over 900 activations have been databased for baseline demographics, disease severity, treatments, complications and follow up from 24,48, 72 hours, 7, 30, 60, 90 and 365 day outcomes. The data set is available if you or your house staff have research interests, and we are happy to collaborate. The purpose of this data collection is to eventually contribute to the national PERT consortium database which opens the large registry data to our institution for investigator driven research. Please let me know if you are interested in what’s available.