Episode 11 - Pulmonary Embolism: Part 2 - PERT

In this second segment on pulmonary embolism (PE), we talk to Dr Jimmy Chien, a senior respiratory physician, about developing the PE response team (PERT) at Westmead Hospital. Then we discuss the potential role of VA-ECMO in high-risk PE. The interlude segment is presented by senior emergency physician Dr Kevin Lai.
Theme: 
Pulmonary Embolism.

Participants: 
Dr Jimmy Chien (senior respiratory physician), Dr Kevin Lai (senior emergency physician), Dr Arwen Morath (emergency physician), Dr Pramod Chandru, Harry Hong, Kit Rowe, and Caroline Tyers.  
 
Discussion:
The Use of PE Response Teams (PERT) in the Care of High-Risk Pulmonary Embolism  
  • This is a discussion with senior respiratory physician Dr Jimmy Chien who helped to develop the PERT system at Westmead Hospital. 
  • Within this segment, “Venoarterial Extracorporeal Membrane Oxygenation in Massive Pulmonary Embolism-Related Cardiac Arrest: A Systematic Review” by Scott et al, is also discussed. 
  • The graphs included in this study are examined closely, so we would recommend reviewing this article while listening to this segment.  
Summary:
  • The first place to establish a PE response team was in Massachusetts.  
  • It took 2 years to form the PE response team at Westmead Hospital (involving a respiratory physician, an ED physician, an intensivist, an interventional radiologist, a vascular surgeon, and a haematologist). 
  • We call a PERT call for patients who have high or intermediate-risk PE.  
  • High-risk PE entails a patient with haemodynamic instability (in whom mortality lies between 25-50%). 
  • Within the intermediate group, there are two subdivisions: intermediate high-risk (with radiological signs of RV strain with an increase in troponin or pro-BNP) and intermediate low-risk (with either evidence of RV strain OR a troponin rise, or a PE-severity index score class III-IV).  
  • When looking within the high-risk PE group, the age group with the worst outcomes (both in PE and with thrombolysis) was those aged > 65 years.  
  • The study exploring VA-ECMO in patients with high-risk PE and cardiac arrest (detailed above) also demonstrated that survival rates below the age of 65 years were relatively high, while those over the age of 65 years had a significantly higher mortality rate. 
  • The Westmead PERT team has data on 52 patients thus far; of whom 21% were high-risk, 58% were intermediate high-risk and 21% were intermediate low-risk. 
  • The most recent analysis of mortality for the Westmead PERT team high-risk PE patients demonstrated a mortality rate of only 10% (compared with the previously stated 25-50%).  
Take-Home Points:
  • In addition, the length of stay for these patients managed by the PERT team has been reduced from 13 days pre-PERT to around 8.5 days.  
  • The PERT team facilitates high-level nuanced conversations dependent on the clinical judgment, experience, and knowledge of the specialists involved. 
  • The development of this PERT team has resulted in improved outcomes for PE patients, and more streamlined care for these patients while in the emergency department and on the ward.  

References: 
  • Scott, J., Gordon, M., Vender, R., Pettigrew, S., Desai, P., Marchetti, N., Mamary, A., Panaro, J., Cohen, G., Bashir, R., Lakhter, V., Roth, S., Zhao, H., Toyoda, Y., Criner, G., Moores, L. and Rali, P., 2021. Venoarterial Extracorporeal Membrane Oxygenation in Massive Pulmonary Embolism-Related Cardiac Arrest: A Systematic Review*. Critical Care Medicine, 49(5), pp.760-769. 
  • Piazza, G., Hohlfelder, B., Jaff, M., Ouriel, K., Engelhardt, T., Sterling, K., Jones, N., Gurley, J., Bhatheja, R., Kennedy, R., Goswami, N., Natarajan, K., Rundback, J., Sadiq, I., Liu, S., Bhalla, N., Raja, M., Weinstock, B., Cynamon, J., Elmasri, F., Garcia, M., Kumar, M., Ayerdi, J., Soukas, P., Kuo, W., Liu, P. and Goldhaber, S., 2015. A Prospective, Single-Arm, Multicenter Trial of Ultrasound-Facilitated, Catheter-Directed, Low-Dose Fibrinolysis for Acute Massive and Submassive Pulmonary Embolism. JACC: Cardiovascular Interventions, 8(10), pp.1382-1392. 
  • Herzallah, K., Saleh, Y., Elkinany, S., Abdelkarim, O., Abdelnabi, M. and Almaghraby, A., 2020. Saddle pulmonary embolism successfully managed by thrombus aspiration followed by ultrasound-enhanced catheter-directed thrombolysis. Journal of the American College of Cardiology, 75(11), p.2445. 

Credits:
This episode was produced by the ­­­­Emergency Medicine Training Network 5 with the assistance of Dr Kavita Varshney and, Deepa Dasgupta. 


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See you next time,
Caroline, Kit, Pramod, Samoda, and Shreyas.

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