A 48-year-old woman with recently diagnosed interstitial lung disease (ILD) presented with several weeks of progressive dyspnea on exertion and new bilateral lower extremity swelling. She was mildly tachycardic (110/min), normotensive (110/80), and hypoxemic requiring 15 liters high-flow nasal cannula. Her cardiac physical exam revealed a loudly split S2, elevated jugular venous pulsations, bibasilar crackles, and bilateral pitting edema to mid-shins. Pulmonary exam revealed bibasilar crackles. Labs were notable for a troponin of 0.07 and BNP of 1310. ECG demonstrated evidence of right ventricular (RV) hypertrophy. Chest x-ray revealed patchy opacities at both lung bases.
A transthoracic echocardiogram demonstrated RV dilation with septal bowing. Subsequent chest CT revealed multiple new segmental PEs. The hospital medicine team communicated with pulmonary and interventional radiology consultants to discuss the possibility of thrombolysis. Given the patient’s hemodynamic stability and presumed chronicity of RV strain in the setting of ILD, systemic or catheter-directed thrombolysis for this submassive PE was not pursued. Intravenous heparin therapy was started and the patient was cautiously diuresed.
On the second day of hospitalization, the patient experienced increased shortness of breath and hypoxemia necessitating intubation. During intubation, she developed PEA arrest. Intravenous alteplase (tPA) was administered given concern for progression of submassive PE and development of obstructive shock. Despite tPA and attempted resuscitation, the patient did not have return of spontaneous circulation and died.
Hospitalists commonly care for patients with acute submassive PE and often stand at the center of complex, multidisciplinary discussion about the optimal acute therapy. These cases present a unique challenge due to the lack of consensus treatment guidelines and the small, yet significant, number of cases that progress to massive PE and decompensation. These consultations and decisions are both time-intensive and time-sensitive.
Multiple factors contributed to this patient’s mortality: 1) the patient’s clinical complexity with underlying ILD, 2) conflicting data surrounding the best available therapy, and 3) lack of clear monitoring parameters. Her initial hemodynamic stability warranted treatment with IV heparin alone. However, evidence of her decompensating RV function and low risk for thrombolysis-related complications may have indicated stronger consideration of either systemic or catheter-directed thrombolysis.
In response to these cases of clinical equipose, innovative PE-specific rapid response teams (PERTs) have been developed. PERTs are composed of providers from multiple disciplines that urgently assess acute PE cases at risk of decompensation and convene to create an individualized, risk-benefit decision for monitoring and treatment. PERTs may represent a new paradigm for optimizing inpatient PE management.
In this case, the formalized structure of a PERT could have fostered rapid dialogue among all providers and may have resulted in either earlier thrombolysis or more precise contingency planning.
To cite this abstract:Esmaili, A; Raffel, K; Narayana, S . CLINICAL EQUIPOISE IN PE MANAGEMENT: CALL A PERT!. Abstract published at Hospital Medicine 2017, May 1-4, 2017; Las Vegas, Nev. Abstract 437. Journal of Hospital Medicine. 2017; 12 (suppl 2). https://www.shmabstracts.com/abstract/clinical-equipoise-in-pe-management-call-a-pert/. Accessed March 20, 2019.