Catheter-directed thrombolysis (CDT) delivers a low dose of a thrombolytic agent directly into the pulmonary artery or into the thrombus. Typically, alteplase is infused as a continuous infusion of 0.5–1.0mg/h for up to 24hours, resulting in the patient receiving about one-third of the systemic thrombolysis dose. Given the local delivery and the reduced dose, CDT may cause less life-threatening bleeds such as ICH or gastrointestinal bleeding, while increasing efcacy by achieving higher con­centrations at the site of the thrombus [25]. Uni-Fuse (AngioDynamics), Cragg­McNamara (Medtronic), and Fountain infusion system (Merit Medical) are examples of CDT.

While increased compliance with treatment algorithms, facilitation of medica­tion ordering and administration, and access to drug information, including review of potential contraindications to therapy, have been seen with pharmacist involve­ment in other response teams (e.g., cardiopulmonary arrest, stroke, sepsis), there is

The largest retrospective, observational study of 573 adult patients with massive or submassive PE sought to describe the role of the pharmacist on the PERT team (n=137 pre-PERT and n=436 post-PERT). The pharmacist participated in the care of 70% of patients in the post-PERT group and intervened in 73% of those cases, with the majority of interventions involving a pharmacist facilitating the ordering or administration of the anticoagulant or thrombolytic (58%). The post-PERT groups had signicantly shorter median times from diagnosis to anticoagulation adminis­tration (post-PERT with a pharmacist, 63minutes versus post-PERT without a phar­macist, 75.5minutes) compared to the pre-PERT group (104minutes), p=0.0001. Additionally, signicantly more patients in the post-PERT groups received LMWH compared to UFH when a pharmacist was involved (69.5%) versus without a phar­macist (53.3%), p = 0.0019. Post-PERT groups had signicantly reduced major bleeding events (post-PERT with a pharmacist, 4.6% versus post-PERT without a pharmacist, 9.9%) compared to the pre-PERT group (14.6%), p=0.0013 [37]. A small retrospective, observational study of 32 patients found that the median time to thrombolytic administration was signicantly shorter after the introduction of a pharmacist as a member of the PERT (23minutes versus 54minutes, p=0.007) [9]. Additionally, an exploratory analysis revealed that a higher percent of patients had an aPTT obtained before restarting the anticoagulant in the post-intervention group (84.6%) compared to the pre-intervention group (68.8%), which may account for the longer median time to resumption of anticoagulation after systemic thromboly­sis seen in the post-intervention group (312minutes versus 115.5minutes) [9].

A retrospective study characterized anticoagulant prescribing patterns in patients evaluated by a PERT that included a pharmacist member [61]. Of the 209 patients prescribed anticoagulation at discharge, DOACs were the most common agent (47.4%) followed by warfarin (29.2%) and LMWH (23.4%). The most common intervention made was the initiation of a DOAC upon discharge; however, patients

removed from all standardized order sets, treatment protocols, and ADCs to avoid confusion [17, 18, 40, 104]. Pharmacists can promote culture change by using full generic or brand name when discussing thrombolytics and providing instruction and feedback to prescribers to refrain from using these abbreviations. Some institutions have congured their electronic medical record (EMR) to automatically correct the full drug name if a thrombolytic abbreviation is entered [19].

Order sets should be clearly labeled for a given indication and guide clinicians to select the correct drug, dose, and administration time for that indication (SCCM Drug Shortage Alert 2023). Other safety measures that may be implemented within the EMR to reduce errors include adding weight-based dose limits, dual sign-offs of an independent double-check among healthcare providers prior to drug administra­tion, and requiring nurses to document patient monitoring post-thrombolytic admin­istration [19]. An extra safety layer exists for institutions that have implemented EMR interoperability with infusion pumps and barcode scanning, which provides a double-check of the right patient, drug, dose, and administration rate [19].

64, 109]. Given these ndings, an initial dose cap of 150mg per dose can be con-

monitoring due to the lack of efcacy data [59]. In patients with heparin-induced thrombocytopenia, fondaparinux is a reasonable alternative despite solid data and potential for minor transplacental passage [3, 23, 59]. Systemic thrombolytics are considered a relative contraindication in pregnant patients. The risks and benets should be weighed cautiously, and the standard recommendations for thrombolytic therapy should be followed for high-risk and intermediate-high-risk patients. In patients who are breastfeeding, LMWH and VKA can be used safely. DOACs should be avoided given the lack of fetal safety and efcacy prole [59]. Fondaparinux, danaparoid, and UFH are potential options.