2019san antonio advanced lung symposium disclosure pe ... · sub‐massive pe vs massive pe...
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PE Response TeamPavan Thangudu, MD
San Antonio Advanced Lung SymposiumDecember 7, 2019
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PE Response Team: What is Our Why?Pavan K Thangudu, MD
ICU Co‐Director of Methodist Hospital
Methodist Hospital PERT Team Leader
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Disclosure• Nothing to disclose
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PE Response TeamPavan Thangudu, MD
San Antonio Advanced Lung SymposiumDecember 7, 2019
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22 M
HR 129
BP: 130/67
SHOCK INDEX < 1
(HR/SBP)
•TroponinI: 0.05•BNP: 494•Lactic:1.9
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Anticoagulation Systemic Thrombolysis
ThrombectomyCatheter Directed Thrombolysis
How Should we Proceed?
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Surgical Thrombectomy
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Surgical Thrombectomy
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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
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High Risk Pulmonary Emboli
Sub‐Massive
PEHemodynamic Instability
Massive PE
Death
RV DysfunctionMortality of 25%
RV FAILURE
Mortality of 58%
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PE Response TeamPavan Thangudu, MD
San Antonio Advanced Lung SymposiumDecember 7, 2019
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Sub‐Massive PE
Massive PE Death
Which do we Treat?
The Clot The Right Ventricle
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PE Response TeamPavan Thangudu, MD
San Antonio Advanced Lung SymposiumDecember 7, 2019
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22 M
HR 129
BP: 130/67
SHOCK INDEX < 1
•TroponinI: 0.05•BNP: 494•Lactic:1.9
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Anticoagulation Systemic Thrombolysis
ThrombectomyCatheter Directed Thrombolysis
How Should we Proceed?
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Surgical Thrombectomy
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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.
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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
Cohort 223% Reduction in 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
Cohort 326% Reduction in RV/LV Ratio
6 (h) EKOS ™ Duration | 6/12 mg r‐tPA*
P<0.0001
1.51
1.030.5
1
1.5
2
Baseline 48 Hour
RV/LV Ratio
Cohort 426% Reduction in RV/LV Ratio
6 (h) EKOS ™ Duration | 12/24 mg r‐tPA*
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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PE Response TeamPavan Thangudu, MD
San Antonio Advanced Lung SymposiumDecember 7, 2019
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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.
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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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PE Response TeamPavan Thangudu, MD
San Antonio Advanced Lung SymposiumDecember 7, 2019
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Anticoagulation Systemic Thrombolysis
ThrombectomyCatheter Directed Thrombolysis
How Should we Proceed?
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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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WHY DOES MASSIVE PE KILL PATIENTS?
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PE Response TeamPavan Thangudu, MD
San Antonio Advanced Lung SymposiumDecember 7, 2019
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Sub‐Massive PE
Massive PE Death
Which do we Treat?
The Clot The Right Ventricle
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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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PE Response TeamPavan Thangudu, MD
San Antonio Advanced Lung SymposiumDecember 7, 2019
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AnticoagulationSystemic
Thrombolysis
ThrombectomyCatheter Directed Thrombolysis
210‐575‐PERTMechanical Circulatory Support
Surgical Thrombectomy
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Systemic Thrombolysis VA ECMO
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PE Response TeamPavan Thangudu, MD
San Antonio Advanced Lung SymposiumDecember 7, 2019
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tPA FAILS
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tPA kills
60% 15%
8%
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EKOS won’t work
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EKOS EKOS
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PE Response TeamPavan Thangudu, MD
San Antonio Advanced Lung SymposiumDecember 7, 2019
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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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PE Response TeamPavan Thangudu, MD
San Antonio Advanced Lung SymposiumDecember 7, 2019
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VAECMO
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• Right Ventricle Unloading• Fibrinolytic• Provides oxygenation support• Minimizes need for vasopressors and inotropes
• Minimizes need for Mechanical Ventilation
VAECMO
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High Risk Pulmonary Emboli
Sub‐Massive
PEHemodynamic Instability
Massive PE
Death
RV DysfunctionMortality of 25%
RV FAILURE
Mortality of 58%
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PE Response TeamPavan Thangudu, MD
San Antonio Advanced Lung SymposiumDecember 7, 2019
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Sub‐Massive PE
Massive PE Death
Which do we Treat?
The Clot The Right Ventricle
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50 MHR 120BP: 164/89O2: 80% on RASHOCK INDEX < 1
•Troponin I: 0.14•BNP: 29•Lactic:0.91
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PE Response TeamPavan Thangudu, MD
San Antonio Advanced Lung SymposiumDecember 7, 2019
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tpA VA ECMO
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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%
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Methodist PERT Structure
Referring Physician
Critical Care Team
Radiology
Cardiology MCS team Hospitalist
Administration
Patient Placement
NursingPharmacy
Marketing
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PE Response TeamPavan Thangudu, MD
San Antonio Advanced Lung SymposiumDecember 7, 2019
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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
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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
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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
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IS THE PE MASSIVE?
• SHOCK INDEX > 1
• SBP < 90
• LACTATE > 2
• SYNCOPE
• Cardiac Arrest
• Vasopressors/Inotropes
• SaO2 < 90% or INCREASING OXYGEN REQUIREMENT
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• 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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PE Response TeamPavan Thangudu, MD
San Antonio Advanced Lung SymposiumDecember 7, 2019
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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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PE Response TeamPavan Thangudu, MD
San Antonio Advanced Lung SymposiumDecember 7, 2019
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AnticoagulationSystemic
Thrombolysis
ThrombectomyCatheter Directed Thrombolysis
210‐575‐PERTMechanical Circulatory Support
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• 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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PE Response TeamPavan Thangudu, MD
San Antonio Advanced Lung SymposiumDecember 7, 2019
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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
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• Right Ventricle Unloading• Fibrinolytic• Provides oxygenation support• Minimizes need for vasopressors and inotropes
• Minimizes need for Mechanical Ventilation
VAECMO
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PE Response TeamPavan Thangudu, MD
San Antonio Advanced Lung SymposiumDecember 7, 2019
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WHICH MORTALITY RATE would you offer your
patient?60% or 5% Please call
210‐575‐PERT
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© 2017 Methodist Healthcare. Confidential: Contains proprietary information. Not intended for external distribution.
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San Antonio Advanced Lung SymposiumDecember 7, 2019
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