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Evaluation of Dyspnea and Management of Pulmonary Embolism after Surgery

11/1/2014 - Sabrina N. Wyatt, MD

Mentor:  Todd Jenkins, MD

Editor:  Eduardo Lara-Torre, MD

The differential diagnosis for dyspnea in a patient after gynecologic surgery should include atelectasis, pneumonia, and pulmonary thromboembolism (PTE).  Atelectasis is the most common cause, occurring in 15-20% of patients after abdominal surgery.  It is usually the result of limited deep breathing due to postoperative pain and immobility.  Preventive strategies such as incentive spirometry and early ambulation should be encouraged.

Pneumonia should be considered in patients with dyspnea and clinical signs of infection including fever, leukocytosis, and purulent sputum.  Evaluation should include a chest radiograph to determine if an infiltrate is present.  Management of pneumonia includes initiation of intravenous antibiotics.

Acute PTE has various presentations depending on the size and location of the thrombus.  Despite perioperative prevention strategies based on risk stratification, thromboembolic events still occur, and dyspnea accompanied by tachycardia, hypoxia, pleuritic chest pain, and/or cough are the most common symptoms. Hemodynamic stability should also be considered.

Clinical symptoms of PTE are nonspecific.  An assessment tool, such as the modified Wells criteria, may be of benefit.  A score greater than 4.0 (high probability) is considered a positive result (PTE likely).  If the patient is stable and PTE is considered likely, CT pulmonary angiography should be performed.  While CT pulmonary angiography is sensitive and specific for identifying PTE (83% and 96%, respectively), initial alternate testing utilizing D-dimer, Doppler ultrasound, or both may be indicated in patients in whom there is an uncertain clinical suspicion (low or intermediate probability).

 

Modified Wells Criteria      

 

Score

     

Clinical symptoms of DVT (Leg swelling/Pain with palpation in deep vein region)

 

3

     

Other dx less likely

 

3

     

Heart Rate > 100

 

1.5

     

Immobilization/Surgery

 

1.5

     

Prior DVT/PTE

 

1.5

     

Hemoptysis

 

1

     

Malignancy

 

1

     

PTE Likely >4.0

   

PTE Unlikely ≤=4.0

   

 

Management of a patient with a suspected PTE should focus on the clinical status and resuscitative efforts required.  Hypoxemia requires oxygen supplementation and can require intubation if severe.  Hypotension may occur.  Management should include intravenous fluids in small amounts (500 mL), and vasopressor support if necessary.  In severe cases, thrombolytic therapy may be considered.  However, the mainstay of PTE treatment is anticoagulation.  Immediate anticoagulation should be initiated during evaluation when there is a high clinical suspicion (>4) and where diagnostic assessment will be delayed more than four hours.  Options for initial anticoagulation include subcutaneous low molecular weight heparin (LMWH), intravenous unfractionated heparin (UFH), and subcutaneous UFH.  The choice of therapy depends on factors such as the risk of postoperative bleeding and renal function.  The transition to oral anticoagulation with warfarin or rivaroxaban should begin within 24-48 hours in those at low risk for bleeding.  Depending on the agent used, monitoring for therapeutic efficacy may be needed.  There is no single recommendation for the length of time oral anticoagulation should be continued.  Many times, it is stopped after 3-6 months, but should be continued for a longer period of time if other predisposing conditions are present.

Initial approval January 2015; Revised January 2018

 

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The Foundation for Exxcellence in Women’s Health, Inc (“Foundation”) is committed to accuracy and will review and validate all Pearls on an ongoing basis to reflect current practice.

This document is designed to aid practitioners in providing appropriate obstetric and gynecologic care. Recommendations are derived from major society guidelines and high quality evidence when available, supplemented by the opinion of the author and editorial board when necessary. It should not be construed as dictating an exclusive course of treatment or procedure to be followed.

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