You are called by the ED for a 56 year old
female who is about 24 days post op from a Left THR, brought back to the ED
from rehab with dyspnea and noted to be in severe distress. Saturating about
92% on 15L high flow cannula. Tachycardic @ 115. BP is ok 137/64. Chest
xray was normal. EKG was ST with no ischemia. Troponin mildly elevated at
0.945. She appears clammy and diaphoretic. Lactate was 2.4. Stat CT angio was
completed in ED with B/L acute PE involving proximal pulmonary arteries with
extension into the segmental arteries. RV:LV ratio was 1.1. ECHO has been
ordered. You note the pt was taking 162mg BID aspirin for extended spectrum DVT
prophylaxis post operativly. What are your next steps?
Consider performing an embolectomy. Although this patient has no contraindications to anticoagulation and no hypotension at this time, she does seem to have severe hypoxia requiring 15L of heated high flow NC and the severe clot on CT that is bilateral. Before deciding on if the patient would receive the embolectomy rather than the anticoagulation, I would like the results of the echo to know if the patient is having right heart failure first. I would first put the patient on IV heparin drip since I am considering embolectomy at all.
ReplyDeletehttps://www.uptodate.com/contents/thrombolytic-fibrinolytic-therapy-in-acute-pulmonary-embolism-and-lower-extremity-deep-vein-thrombosis?topicRef=8253&source=see_link
http://www.uky.edu/~achan2/pics/med/PE-anti-coag.pdf
By this description, the patient appears to have a submassive PE. It is unknown what the echo results are to indicate the presence of RV dysfunction, but the patient's BP is normal. If this was a massive PE, the patient would have either sustained hypotension for greater than 15 minutes (sbp <90 mmHg) or a sustained significant drop in systolic blood pressure (>40 mmHg). This patient does not appear to have a contraindication to anticoagulation, so IVC filter is not required. Anticoagulation would be very important, as it decreases mortality in patients with PE. Options would be heparin or LMWH if heparin is contraindicated. If this patient did become hypotensive or echo came back demonstrating significant RV dysfunction, thrombolytics are justified. Embolectomy would be considered, again, if this patient was hypotensive or had RV dysfunction. The patient does not appear to be hemodynamically unstable currently, so fluids would not be necessary at this time. The patient is not hypoxic to the point of requiring mechanical ventilation.
ReplyDeleteAnaesthesia and Intensive Care Medicine Vol 11:12, page 512-518
Essentially, this case is a high risk bleeding patient since he recently had a total hip surgery 24 days ago that developed bilateral pulmonary embolism and needs anti-coagulation. The patient is hemodynamically stable for now because his blood pressure is >90 systolic and is saturating 92% on 15L on high flow. If the patient were to become unstable by dropping blood pressure and requiring more oxygen to saturate appropriately it would be necessary to add vasopressors and intubate the patient to protect his airway. Also, pulmonary embolism with associated right ventricular failure is prone to have hypotension and require the measures stated above. The echocardiogram can help us distinguish if the patient has RV failure. If so, aggressive fluids can be more harmful than beneficial.
ReplyDeleteSince the patient had surgery 24 days ago, anti-coagulation is contraindicated due to increased risk of bleeding. Alternative therapies include embelectomy and insertion of an IVC filter. If the patient was stable and had no contraindication for anti-coagulation, low molecular weight heparin would be necessary. If the patient was unstable with no contraindications for anti-coagulation, unfractionated heparin would be appropriate.
https://www.uptodate.com/contents/treatment-prognosis-and-follow-up-of-acute-pulmonary-embolism-in-adults#H366903997
Andrew Lee
ReplyDeleteThis patient is having a submassive PE with right heart strain. This patient needs tPA and anticoagulation.
https://www.uptodate.com/contents/thrombolytic-fibrinolytic-therapy-in-acute-pulmonary-embolism-and-lower-extremity-deep-vein-thrombosis?topicRef=8253&source=see_link
This patient has a post-operative pulmonary embolism and requires anticoagulation which should have been already started based on the high suspicion. Given the additional findings this would be considered a submassive PE and patient is a candidate for tPA.
ReplyDeletePEITHO trial, MOPETT trial
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