A Multidisciplinary Pulmonary Embolism Response Team
2013; Elsevier BV; Volume: 144; Issue: 5 Linguagem: Inglês
10.1378/chest.13-1562
ISSN1931-3543
AutoresChristopher Kabrhel, Michael R. Jaff, Richard N. Channick, Joshua N. Baker, Kenneth Rosenfield,
Tópico(s)Acute Myocardial Infarction Research
ResumoTo the EditorIn this report, we describe the successful introduction of a novel Pulmonary Embolism Response Team (PERT) to streamline the care of patients with severe pulmonary embolism (PE). The treatment of patients with massive and submassive PE remains controversial.1Jaff MR McMurtry MS Archer SL American Heart Association Council on Cardiopulmonary, Critical Care, Perioperative and Resuscitation; American Heart Association Council on Peripheral Vascular Disease; American Heart Association Council on Arteriosclerosis, Thrombosis and Vascular Biology et al.Management of massive and submassive pulmonary embolism, iliofemoral deep vein thrombosis, and chronic thromboembolic pulmonary hypertension: a scientific statement from the American Heart Association.Circulation. 2011; 123: 1788-1830Crossref PubMed Scopus (1544) Google Scholar Different specialists bring different experience, technical expertise, and therapeutic recommendations.1Jaff MR McMurtry MS Archer SL American Heart Association Council on Cardiopulmonary, Critical Care, Perioperative and Resuscitation; American Heart Association Council on Peripheral Vascular Disease; American Heart Association Council on Arteriosclerosis, Thrombosis and Vascular Biology et al.Management of massive and submassive pulmonary embolism, iliofemoral deep vein thrombosis, and chronic thromboembolic pulmonary hypertension: a scientific statement from the American Heart Association.Circulation. 2011; 123: 1788-1830Crossref PubMed Scopus (1544) Google Scholar, 2Imberti D Ageno W Manfredini R et al.Interventional treatment of venous thromboembolism: a review.Thromb Res. 2012; 129: 418-425Abstract Full Text Full Text PDF PubMed Scopus (41) Google Scholar To provide optimal care for complex patients with PE, a team approach is required. We formed the PERT with an infrastructure that would provide rapid, multidisciplinary consultation; mobilize resources; and facilitate research.The PERT is composed of specialists in cardiology, emergency medicine, vascular medicine, cardiac surgery, and pulmonary/critical care with an interest in PE. We created an activation system consistent with published guidelines for rapid response teams.3Devita MA Bellomo R Hillman K et al.Findings of the first consensus conference on medical emergency teams [published correction appears in Crit Care Med. 2006;34(12):3070].Crit Care Med. 2006; 34: 2463-2478Crossref PubMed Scopus (572) Google Scholar, 4Jones DA DeVita MA Bellomo R Rapid-response teams.N Engl J Med. 2011; 365: 139-146Crossref PubMed Scopus (493) Google Scholar An on-call PERT fellow responds to an activation and immediately convenes an online meeting of PERT members using commercially available software. This system enables team members to discuss the case while viewing data and radiologic images from any computer or mobile device via a password-protected login.In the first 12 weeks, there were 30 unique PERT activations. Most (17, 57%) originated in the ED, seven (23%) in ICUs, and six (20%) in inpatient hospital units. Twenty-five activations (83%) were for confirmed PE and five (17%) for unstable patients with suspected PE. Median elapsed time from the initial activation to the multidisciplinary online meeting was 54 min (25%-75%: 52–72 min). Data collection was approved by the Human Research Committee of Partners Healthcare (2012P002257).The mean age of patients was 57 ± 17 years, and 19 (63%) were men (Table 1). Seven of 25 confirmed PEs (28%) were saddle and eight (32%) involved a main pulmonary artery. Twenty patients (80%) had right-sided heart strain. After consultation, the PERT considered 18 PEs (72%) submassive and two (8%) massive (Fig 1). Two patients (8%) were treated with thrombolysis (via catheter), 12 (40%) had a contraindication to thrombolysis, and five (20%) had a vena cava filter placed. Three patients (12%) with confirmed PE died.Table 1Characteristics of Enrolled PatientsCharacteristicNo.%Age, y, mean (SD)5717Male1963Comorbid illness Cardiopulmonary diseaseaIncludes any history of coronary artery disease, congestive heart failure, asthma, COPD, or interstitial pulmonary fibrosis.1033 Prior VTE310 Cancer827 Recent surgery or traumabWithin 4 wk of PE.827 Recent hospitalizationbWithin 4 wk of PE.1033PE category Suspected517 Low risk517 Submassive1860 Massive27PE location Saddle728 Main pulmonary artery832 Lobar pulmonary artery936 Segmental pulmonary artery14 Bilateral2080PE severity Right-sided heart straincBased on echocardiogram or CT pulmonary angiogram.2080 Troponin ≥ 0.01 ng/mL1664 NT-proBNP ≥ 900 pg/mL1352 Residual DVT presentdBased on extremity ultrasound or CT venography.1664Clinical severity Endotracheally intubatedeEndotracheally intubated at time of Pulmonary Embolism Response Team activation.827 Admitted to ICU1653NT-proBNP = N-terminal pro-brain natriuretic peptide; PE = pulmonary embolism.a Includes any history of coronary artery disease, congestive heart failure, asthma, COPD, or interstitial pulmonary fibrosis.b Within 4 wk of PE.c Based on echocardiogram or CT pulmonary angiogram.d Based on extremity ultrasound or CT venography.e Endotracheally intubated at time of Pulmonary Embolism Response Team activation. Open table in a new tab To the authors' knowledge, the PERT at Massachusetts General Hospital is the first such team in the country. Our initial experience suggests that an innovative, multidisciplinary PERT can streamline the care of patients with severe PE and that there is high demand for this approach. To the EditorIn this report, we describe the successful introduction of a novel Pulmonary Embolism Response Team (PERT) to streamline the care of patients with severe pulmonary embolism (PE). The treatment of patients with massive and submassive PE remains controversial.1Jaff MR McMurtry MS Archer SL American Heart Association Council on Cardiopulmonary, Critical Care, Perioperative and Resuscitation; American Heart Association Council on Peripheral Vascular Disease; American Heart Association Council on Arteriosclerosis, Thrombosis and Vascular Biology et al.Management of massive and submassive pulmonary embolism, iliofemoral deep vein thrombosis, and chronic thromboembolic pulmonary hypertension: a scientific statement from the American Heart Association.Circulation. 2011; 123: 1788-1830Crossref PubMed Scopus (1544) Google Scholar Different specialists bring different experience, technical expertise, and therapeutic recommendations.1Jaff MR McMurtry MS Archer SL American Heart Association Council on Cardiopulmonary, Critical Care, Perioperative and Resuscitation; American Heart Association Council on Peripheral Vascular Disease; American Heart Association Council on Arteriosclerosis, Thrombosis and Vascular Biology et al.Management of massive and submassive pulmonary embolism, iliofemoral deep vein thrombosis, and chronic thromboembolic pulmonary hypertension: a scientific statement from the American Heart Association.Circulation. 2011; 123: 1788-1830Crossref PubMed Scopus (1544) Google Scholar, 2Imberti D Ageno W Manfredini R et al.Interventional treatment of venous thromboembolism: a review.Thromb Res. 2012; 129: 418-425Abstract Full Text Full Text PDF PubMed Scopus (41) Google Scholar To provide optimal care for complex patients with PE, a team approach is required. We formed the PERT with an infrastructure that would provide rapid, multidisciplinary consultation; mobilize resources; and facilitate research.The PERT is composed of specialists in cardiology, emergency medicine, vascular medicine, cardiac surgery, and pulmonary/critical care with an interest in PE. We created an activation system consistent with published guidelines for rapid response teams.3Devita MA Bellomo R Hillman K et al.Findings of the first consensus conference on medical emergency teams [published correction appears in Crit Care Med. 2006;34(12):3070].Crit Care Med. 2006; 34: 2463-2478Crossref PubMed Scopus (572) Google Scholar, 4Jones DA DeVita MA Bellomo R Rapid-response teams.N Engl J Med. 2011; 365: 139-146Crossref PubMed Scopus (493) Google Scholar An on-call PERT fellow responds to an activation and immediately convenes an online meeting of PERT members using commercially available software. This system enables team members to discuss the case while viewing data and radiologic images from any computer or mobile device via a password-protected login.In the first 12 weeks, there were 30 unique PERT activations. Most (17, 57%) originated in the ED, seven (23%) in ICUs, and six (20%) in inpatient hospital units. Twenty-five activations (83%) were for confirmed PE and five (17%) for unstable patients with suspected PE. Median elapsed time from the initial activation to the multidisciplinary online meeting was 54 min (25%-75%: 52–72 min). Data collection was approved by the Human Research Committee of Partners Healthcare (2012P002257).The mean age of patients was 57 ± 17 years, and 19 (63%) were men (Table 1). Seven of 25 confirmed PEs (28%) were saddle and eight (32%) involved a main pulmonary artery. Twenty patients (80%) had right-sided heart strain. After consultation, the PERT considered 18 PEs (72%) submassive and two (8%) massive (Fig 1). Two patients (8%) were treated with thrombolysis (via catheter), 12 (40%) had a contraindication to thrombolysis, and five (20%) had a vena cava filter placed. Three patients (12%) with confirmed PE died.Table 1Characteristics of Enrolled PatientsCharacteristicNo.%Age, y, mean (SD)5717Male1963Comorbid illness Cardiopulmonary diseaseaIncludes any history of coronary artery disease, congestive heart failure, asthma, COPD, or interstitial pulmonary fibrosis.1033 Prior VTE310 Cancer827 Recent surgery or traumabWithin 4 wk of PE.827 Recent hospitalizationbWithin 4 wk of PE.1033PE category Suspected517 Low risk517 Submassive1860 Massive27PE location Saddle728 Main pulmonary artery832 Lobar pulmonary artery936 Segmental pulmonary artery14 Bilateral2080PE severity Right-sided heart straincBased on echocardiogram or CT pulmonary angiogram.2080 Troponin ≥ 0.01 ng/mL1664 NT-proBNP ≥ 900 pg/mL1352 Residual DVT presentdBased on extremity ultrasound or CT venography.1664Clinical severity Endotracheally intubatedeEndotracheally intubated at time of Pulmonary Embolism Response Team activation.827 Admitted to ICU1653NT-proBNP = N-terminal pro-brain natriuretic peptide; PE = pulmonary embolism.a Includes any history of coronary artery disease, congestive heart failure, asthma, COPD, or interstitial pulmonary fibrosis.b Within 4 wk of PE.c Based on echocardiogram or CT pulmonary angiogram.d Based on extremity ultrasound or CT venography.e Endotracheally intubated at time of Pulmonary Embolism Response Team activation. Open table in a new tab To the authors' knowledge, the PERT at Massachusetts General Hospital is the first such team in the country. Our initial experience suggests that an innovative, multidisciplinary PERT can streamline the care of patients with severe PE and that there is high demand for this approach. In this report, we describe the successful introduction of a novel Pulmonary Embolism Response Team (PERT) to streamline the care of patients with severe pulmonary embolism (PE). The treatment of patients with massive and submassive PE remains controversial.1Jaff MR McMurtry MS Archer SL American Heart Association Council on Cardiopulmonary, Critical Care, Perioperative and Resuscitation; American Heart Association Council on Peripheral Vascular Disease; American Heart Association Council on Arteriosclerosis, Thrombosis and Vascular Biology et al.Management of massive and submassive pulmonary embolism, iliofemoral deep vein thrombosis, and chronic thromboembolic pulmonary hypertension: a scientific statement from the American Heart Association.Circulation. 2011; 123: 1788-1830Crossref PubMed Scopus (1544) Google Scholar Different specialists bring different experience, technical expertise, and therapeutic recommendations.1Jaff MR McMurtry MS Archer SL American Heart Association Council on Cardiopulmonary, Critical Care, Perioperative and Resuscitation; American Heart Association Council on Peripheral Vascular Disease; American Heart Association Council on Arteriosclerosis, Thrombosis and Vascular Biology et al.Management of massive and submassive pulmonary embolism, iliofemoral deep vein thrombosis, and chronic thromboembolic pulmonary hypertension: a scientific statement from the American Heart Association.Circulation. 2011; 123: 1788-1830Crossref PubMed Scopus (1544) Google Scholar, 2Imberti D Ageno W Manfredini R et al.Interventional treatment of venous thromboembolism: a review.Thromb Res. 2012; 129: 418-425Abstract Full Text Full Text PDF PubMed Scopus (41) Google Scholar To provide optimal care for complex patients with PE, a team approach is required. We formed the PERT with an infrastructure that would provide rapid, multidisciplinary consultation; mobilize resources; and facilitate research. The PERT is composed of specialists in cardiology, emergency medicine, vascular medicine, cardiac surgery, and pulmonary/critical care with an interest in PE. We created an activation system consistent with published guidelines for rapid response teams.3Devita MA Bellomo R Hillman K et al.Findings of the first consensus conference on medical emergency teams [published correction appears in Crit Care Med. 2006;34(12):3070].Crit Care Med. 2006; 34: 2463-2478Crossref PubMed Scopus (572) Google Scholar, 4Jones DA DeVita MA Bellomo R Rapid-response teams.N Engl J Med. 2011; 365: 139-146Crossref PubMed Scopus (493) Google Scholar An on-call PERT fellow responds to an activation and immediately convenes an online meeting of PERT members using commercially available software. This system enables team members to discuss the case while viewing data and radiologic images from any computer or mobile device via a password-protected login. In the first 12 weeks, there were 30 unique PERT activations. Most (17, 57%) originated in the ED, seven (23%) in ICUs, and six (20%) in inpatient hospital units. Twenty-five activations (83%) were for confirmed PE and five (17%) for unstable patients with suspected PE. Median elapsed time from the initial activation to the multidisciplinary online meeting was 54 min (25%-75%: 52–72 min). Data collection was approved by the Human Research Committee of Partners Healthcare (2012P002257). The mean age of patients was 57 ± 17 years, and 19 (63%) were men (Table 1). Seven of 25 confirmed PEs (28%) were saddle and eight (32%) involved a main pulmonary artery. Twenty patients (80%) had right-sided heart strain. After consultation, the PERT considered 18 PEs (72%) submassive and two (8%) massive (Fig 1). Two patients (8%) were treated with thrombolysis (via catheter), 12 (40%) had a contraindication to thrombolysis, and five (20%) had a vena cava filter placed. Three patients (12%) with confirmed PE died. NT-proBNP = N-terminal pro-brain natriuretic peptide; PE = pulmonary embolism. To the authors' knowledge, the PERT at Massachusetts General Hospital is the first such team in the country. Our initial experience suggests that an innovative, multidisciplinary PERT can streamline the care of patients with severe PE and that there is high demand for this approach.
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