PE Response Teams in the COVID Era

September 29, 2020

Written by Clay Smith

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Pulmonary embolism response teams (PERT) can be a big help in the diagnosis and treatment of acute PE in the COVID-19 era. Here’s how.

Why does this matter?
PERTs can help make evidence-based decisions in acute PE patients, but what should their role be in the midst of COVID-19? Several statements in this paper recommend early testing for COVID-19, an assumption the patient may be positive if unknown, and a default to taking safety precautions. I won’t repeat this in each step, as I assume you’ve got this. This will cover other recommendations.

Blood clots and COVID
This was a consensus statement on use of PERTs during COVID-19. Here are the high points and a handy PERT algorithm for the COVID era.

1. Role of PERT: PERTs still have a role during COVID-19. A multidisciplinary team to diagnose and manage acute PE can positively impact care.

2. Diagnosis of PE: Consider whether the extent of disease on imaging explains the degree of hemodynamic or gas-exchange abnormalities you’re seeing. If worse, a CTPA is probably worth doing. COVID-19 induces hypercoagulability; have a low threshold to workup PE. An elevated D-dimer alone may not necessarily indicate PE, as COVID-19 may cause this.

3. Outpatient PE treatment during COVID-19: It is possible if patients meet criteria – low PESI, no RV dysfunction, etc. – but these patients need very close follow up. Bear in mind, they have a viral pneumonia and a PE.

4. Thrombolysis: Use of thrombolysis is still an option and may be preferable to invasive intervention in some cases for staff safety.

5. Transfer: Transfer for invasive intervention may still be an option but has to be on a case-by-case basis to weigh the risk vs. benefit. This is where a PERT is really helpful. If at a smaller facility, have the conversation early.

6. Follow up: It is ideal for this to be virtual, but if they need a follow up on RV function, that may not be feasible.

7. Safety: Reduce exposure of staff as much as possible, and leverage digital technology to assess imaging, vitals, monitoring, and other tasks whenever possible.

Source
Diagnosis and Treatment of Pulmonary Embolism During the COVID-19 Pandemic: A Position Paper from the National PERT Consortium. Chest. 2020 Aug 27:S0012-3692(20)34287-2. doi: 10.1016/j.chest.2020.08.2064. Online ahead of print.

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