PE after surgery Watch

appleboy786
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ok so if you get a massive PE say a week after a hip replacement would you be contraindicated to give thrombolysis and what would you do to treat it if so?
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arcl
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More information would be needed.

Was the patient on prophylactic DVT treatment post-op? Heparin? Warfarin? What are their INR levels if on warfarin?

Until normal circumstances, I wouldn't think there would be an obvious reason not to thrombolise (considering it's "massive"), unless there are obvious contraindications (eg hx CVA or IC bleeds, pregnancy, issues with blood clotting) - is there a filter? What was the reason for the hip op? Was because of trauma/was there any vascular damage? Is there a risk of a bleed or rebleed? Is there any underlying cause for the PE other than the fact the patient was immobile?

The only thing I could think of if thrombolysis wasn't an option would be a thrombolectomy? Though that's a pretty old school treatment option I think? Hell, I don't even know if it's done any more.
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j00ni
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Recent surgery is a relative contraindication to thrombolysis, so you would assess relative risk:benefit, and basically if the risk to life was greater from the PE than thrombolysis you would probably proceed
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Jamie
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(Original post by arcl)
More information would be needed.

Was the patient on prophylactic DVT treatment post-op? Heparin? Warfarin? What are their INR levels if on warfarin?

Until normal circumstances, I wouldn't think there would be an obvious reason not to thrombolise (considering it's "massive"), unless there are obvious contraindications (eg hx CVA or IC bleeds, pregnancy, issues with blood clotting) - is there a filter? What was the reason for the hip op? Was because of trauma/was there any vascular damage? Is there a risk of a bleed or rebleed? Is there any underlying cause for the PE other than the fact the patient was immobile?

The only thing I could think of if thrombolysis wasn't an option would be a thrombolectomy? Though that's a pretty old school treatment option I think? Hell, I don't even know if it's done any more.
Many of your questions are totally irrelevant.
Question was 'massive PE 1 week after hip replacement. Can you thrombolyse'

Hence:-

"Was the patient on prophylactic DVT treatment post-op? Heparin? Warfarin? What are their INR levels if on warfarin?"
= Irrelevant

is there a filter?
= Irrelevant
issues with blood clotting
= Irrelevant
What was the reason for the hip op?
= Irrelevant
Was because of trauma/was there any vascular damage?
= Irrelevant
Is there a risk of a bleed or rebleed?
= Irrelevant
Is there any underlying cause for the PE other than the fact the patient was immobile?
= Irrelevant


At end of day you need to ask yourself (as j00ni said) risk:benefit.
Ergo if 'massive PE' on CTPA and patient not dying in front of you then don't thombolyse.
If patient arresting/peri-arrest then thrombolyse.

Simples
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Renal
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(Original post by Jamie)
If patient arresting/peri-arrest then thrombolyse.
And refer it to someone else.
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Revenged
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The article might make it clearer.

• Thrombolysis is the first line treatment for massive PE [B] and may be instituted on clinical grounds alone if cardiac arrest is imminent [B]; a 50 mg bolus of alteplase is recommended. [C]

• Thrombolysis should not be used as first line treatment in non-massive PE. [B]

http://www.brit-thoracic.org.uk/Port...olismJUN03.pdf


In a non-massive PE I thought you increase the low molecular weight heparin to therapeutic dose and then convert to warfarin. I'm not sure entire sure if you can do this in a surgical patient because of risk of haemorrhage so perhaps someone could clarify that for you.

HTH
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Renal
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(Original post by Revenged)
In a non-massive PE I thought you increase the low molecular weight heparin to therapeutic dose and then convert to warfarin. I'm not sure entire sure if you can do this in a surgical patient because of risk of haemorrhage so perhaps someone could clarify that for you.
You can. There is a risk of bleeding but, from what I remember, it's not all that high.
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junior.doctor
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Surgical patients can have warfarin - again, it's a case by case risk-benefit weigh up, clinical judgement based on type of surgery vs severity of PE.

The problem with LMWH is that it can't be reversed. The other night I (+ ITU team) were left clearing up the mess after the medics decided to give a patient rx dose clexane for ?PE due to SOB (normal O2 sats). Look at the gas and you find pH 7.15, BE -15, bicarb 12, normal PO2, low PCO2... Respiratory compensation anybody?? To add to the fun no-one had bothered to check and notice the fact that he had a platelet count of 23 pre-clexane, and minimal functioning nephrons. Dx: sepsis (multiple SIRS + urine infec), not PE. Thanks medics.

Moral of the story - it's very easy in medical emergencies to assume someone has a PE and pile in the clexane before a proper examination plus baseline ix such as CXR / gas have been done. Don't forget SOB due to resp compensation for metabolic acidosis!
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Jamie
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(Original post by junior.doctor)
Moral of the story - it's very easy in medical emergencies to assume someone has a PE and pile in the clexane before a proper examination plus baseline ix such as CXR / gas have been done. Don't forget SOB due to resp compensation for metabolic acidosis!
Very good point

Alas "Please rate some other members before rating this member again"
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