key: cord-286403-gdkwabcj authors: Rosovsky, Rachel P.; Grodzin, Charles; Channick, Richard; Davis, George A.; Giri, Jay S.; Horowitz, James; Kabrhel, Christopher; Lookstein, Robert; Merli, Geno; Morris, Timothy A.; Rivera-Lebron, Belinda; Tapson, Victor; Todoran, Thomas M.; Weinberg, Aaron S.; Rosenfield, Kenneth title: Diagnosis and Treatment of Pulmonary Embolism During the COVID-19 Pandemic: A Position Paper from the National PERT Consortium date: 2020-08-27 journal: Chest DOI: 10.1016/j.chest.2020.08.2064 sha: doc_id: 286403 cord_uid: gdkwabcj The co-existence of COVID-19 and PE, two life threatening illnesses, in the same patient presents a unique challenge. Recent guidelines have delineated how best to diagnose and manage patients with PE. However, the unique aspects of this virus confound both the diagnosis and treatment of PE, and thus require modification of established algorithms.1-6 Important considerations include adjustment of diagnostic modalities, incorporation of the pro-thrombotic contribution of COVID-19, management of two critical cardio-respiratory illnesses in the same patient, and protecting patients and health care workers while providing optimal care. The benefits of a team-based approach for decision-making and coordination of care, such as that offered by pulmonary embolism response teams (PERT), has become more evident in this crisis. The importance of careful followup care also is underscored for patients with these two diseases with long-term effects. This position paper from the PERT Consortium specifically addresses issues related to the diagnosis and management of PE in the COVID-19 patient. The National Pulmonary Embolism Response Team (PERT) Consortium, the largest organization in the world specifically dedicated to improving outcomes in PE and advancing the science around this disease, recently published consensus recommendations for the diagnosis, treatment and follow-up for patients with acute PE. 7 Although many of these recommendations apply to patients with PE and COVID-19, some unique factors associated with the pandemic necessitate addressing these patients separately. The current COVID-19 pandemic has illustrated the importance of aggressive evaluation and management, when considering exposure to an highly communicable viral disease that has multisystem effects and a high mortality rate. As such, COVID-19 presents an unprecedented challenge to the health care system, and specifically for individuals directly responsible for delivering care, and for others in the medical environment who could be exposed. Those who become infected are potentially vectors of viral transmittance in our homes, our community and throughout the world. Every exposure can further exacerbate the pandemic. Thus, the goal must be to deliver optimal care without compromise to our patients, while mitigating direct or indirect exposure and spread of the virus. There is emerging evidence that COVID-19 infected patients are prone to thrombosis and pulmonary embolism (PE). 8 Table 1) , and offers a safe and efficient way to diagnose and treat PE without compromising patient care. Please refer to the www.cdc.gov website for the most up to date information specific to COVID-19. • What testing should be performed during follow up? Pulmonary embolism response teams bring together a multi-disciplinary group of specialists to treat patients with severe PE. 13 The goal is to coordinate and expedite the diagnosis and treatment of PE with a team of physicians from different specialties. There is no defined or optimal structure of PERT, and the make up varies by institution. 13 A team may include all or a combination of cardiac surgery, critical care, emergency medicine, hematology, interventional and noninterventional cardiology, interventional radiology pulmonary medicine, vascular medicine, vascular surgery, and pharmacy. Each member brings their expert opinion to the team. 14 One of the main advantages of PERT is that this multi-disciplinary approach occurs in real time and allows for the rapid evaluation of risks, J o u r n a l P r e -p r o o f formulation of a treatment plan that suits each patient, and mobilization of appropriate resources to provide the highest quality of care to patients with PE. 15 This approach, now more than ever, seems essential in the COVID-19 era. Although the exact incidence of VTE associated with COVID-19 is currently unknown, reports range from as low as 1% in the general wards to as high as 31% in intensive care units. 19 However, this study also found that elevations in D-dimer >2500 ng/mL at initial presentation were also predictive of bleeding complications during hospitalization. In the same way, data from China indicated that patients at the highest risk of developing a PE were the same patients at the highest risk of bleeding. 24 At this point and in line with the recently published CHEST guidelines, there is insufficient evidence to recommend using an elevated D-dimer or any other laboratory data to guide clinical practice for VTE diagnosis. 25 Thus, we recommend that biomarkers should not be used in the diagnostic evaluation for suspected DVT or PE. Given the limited data to support the use of biomarkers to diagnosis PE in COVID-19 patients, standard diagnostic testing should be considered ( Figure 1 ). Additional details on specific interventional decision making is found below in the "Interventions" section. Interventions Decisions about procedural intervention should be grounded in a discussion of risk-benefit ratio with a multi-disciplinary PERT consultation. During this pandemic, the relative risks and benefits have shifted, due to the risk of viral transmission with transportation of COVID-19 positive patients to invasive laboratories or opertating rooms. Furthermore, patient circumstances (e.g. proning) may make interventional procedures unsafe or impossible. The evidence base regarding optimal treatment for higher risk PE is evolving and remains unclear as to which patients might benefit from interventional therapies. 38 Given the absence of a well-defined benefit for invasive therapy and the potential for viral transmission, a conservative approach leaning towards medical therapy (e.g. anticoagulation or IV peripheral fibrinolysis) should be considered in patients with COVID- 19 . In general, procedural means of treating PE should be applied to only severe cases in which medical therapy is unlikely to be successful or contraindicated. Presently, there is no data to support one intervention over another and it is a strength of a PERT, using a multidisciplinary discussion platform, to arrive at these decisions based on each patients unique clinical scenario ( Figure 1 ). Hemodynamically stable patients should be medically managed with anticoagulation alone. Careful monitoring is prudent in order to identify patients who become unstable and require emergency intervention. Urgent and emergent cases can be identified as those that, acutely or sub-acutely, develop hemodynamic instability characterized by increasing It is important to note that autopsies have identified microvascular thrombi in COVID -19 infected patients. 41, 42 Unlike most DVT and PE events, the clinical onset of these microthrombi is unknown and lacks specific physical findings or imaging signatures. Position Statement: • Indications and contraindications for thrombolysis remain unchanged. • Given the potential of exposure to other patients and staff, interhospital transfer of COVID-19 patients should only occur when the receiving hospital offers treatment that is imminently needed and beyond the capabilities of the sending hospital. Whenever possible, COVID-19 status should be identified prior to transfer. Physician-to-physician communication should occur regarding the necessity of transfer, as well as the logistics and potential liabilities. Existing hospital transfer policies for PE patients, regardless of COVID-19 status, should incorporate the following: There must be a well-defined clinical benefit or resources or services that are not available at the sending hospital, such as intensive care unit care, endovascular intervention or surgical services, ECMO, and neurosurgical services. PERTs can be instrumental not only to help make the decision as to whether or not to transfer a patient, but also to mobilize the resources and carry out the treatment plans that are deemed necessary once the transfer occurs. All hospital, state and federal guidelines for avoiding viral transmission, including those found on www.cdc.gov HYPERLINK "http://www.cdc.gov/", should be followed in any case of patient transfer. for best care of the patient. Adequate follow up for all PE patients is essential for recovery and for optimal prevention of subsequent thromboembolic events. Such followup is even more critically important in the successful recovery of patients with concomitant COVID-19 and PE. Utlizing PERT follow up clinics can help assure that this crucial piece of care occurs ( Table 2) . If PERT follow up clinics are not available, dedicated hematology, pulmonary or vascular medicine clinics, for example, may provide similar continuity. Prior to discharge, providers must assure appropriate hand off to the next level of When an intervention is necessary for a PE patients with COVID-19, invasive laboratory and operating room (OR) personnel should be kept to the minimum that is required for safe conduct of the procedure, and should don and doff specified and approved personal protective equipment (PPE). Careful planning should be exercised and when possible, the team should anticipate and lay out the resources (medications, instruments, devices) that will potentially be needed so as to expedite the procedure and minimize supply runs. Every precaution should be taken to prevent aerosolization of patient respiratory secretions throughout the procedure. After the procedure, the room should be terminally cleaned, in accordance with hospital policy regarding COVID-19 infection prevention. Position Statement: procedures, particularly with regards to required personnel and equipment, will expedite procedures and minimize staff exposure. The current COVID-19 era has complicated the diagnosis, risk startification and treatment of patients with PE. The PERT approach can significantly aid in the care of these vulnerable and complicated patients. Through a multi-disciplinary clinical discussion, PERTevaluations assess the hemodynamic status, provide cardiopulmonary evaluation, weigh the impact of co-morbid conditions, and define the best anticoagulation or interventional management. Vigilance and special measures are also required for management of such patients, in order to optimize outcome while protecting others in the environment. Modifications of previously defined algorithm for the diagnosis and management of PE must be considered. As more is learned about COVID-19, ongoing refinements will be necessary to address this vulnerable population. The PERT consortium COVID-19 and PE registry will be a reservoir for such information. Visit the PERT website, www.pertconsortium.org for archived and upcoming webinars, COVID-19 and Thrombotic or Thromboembolic Disease: Implications for Prevention, Antithrombotic Therapy, and Follow-up COVID-19 and D-dimer: Frequently Asked Questions Practical guidance for the prevention of thrombosis and management of coagulopathy and disseminated intravascular coagulation of patients infected with COVID-19 BTS Guidance on Venous Thromboembolic Disease in patients with COVID-19 ISTH interim guidance on recognition and management of coagulopathy in COVID-19 Prevention and Treatment of Venous Thromboembolism Associated with Coronavirus Disease 2019 Infection: A Consensus Statement before Guidelines Diagnosis, Treatment and Follow Up of Acute Pulmonary Embolism: Consensus Practice from the PERT Consortium Pulmonary Embolism in COVID-19 Patients: Awareness of an Increased Prevalence Confirmation of the high cumulative incidence of thrombotic complications in critically ill ICU patients with COVID-19: An updated analysis Clinical Characteristics of Covid-19 in New York City Prevalence of venous thromboembolism in patients with severe novel coronavirus pneumonia Epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in Wuhan, China: a descriptive study Pulmonary embolism response teams: Purpose, evidence for efficacy, and future research directions Pulmonary Embolism Response Team: Inpatient Structure, Outpatient Follow-up, and Is It the Current Standard of Care? 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Pulmonary and Cardiac Pathology in Covid-19: The First Autopsy Series from New Orleans. medRxiv Author contributions RR J o u r n a l P r e -p r o o f c Due to the fluid nature of COVID-19 hot spots, the ability to handle COVID positive patients in cath labs and ORs with regard to transport, staff exposure/preparedness, etc. has evolved since the start of the pandemic and will continue to evolve. This algorithm represents how to treat patients in high volume COVID institutions where resources may be limited. In low volume areas, providers may be less likely to shunt a patient down a systemic TPA pathway if the patient would benefit from an invasive therapy and there are no barriers or limited resources.