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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

REVISED PEARL - July 2016

The differential diagnosis for dyspnea in a patient after gynecologic surgery should include atelectasis, pneumonia, and pulmonary thromboembolism (PTE).  Atelectasis is the most common, occurring in 15-20% of patients after abdominal surgery.  It is usually the result of limited deep breathing due to postoperative pain.  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 empiric 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 cough are the most common symptoms.

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 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.

Modified Wells Criteria       Score

 

Clinical symptoms of DVT

(Leg swelling/Pain with palpation in deep vein region)

3.0

Other dx less likely

3.0

Heart Rate > 100

1.5

Immobilization/Surgery

1.5

Prior DVT/PTE

1.5

Hemoptysis

1.0

Malignancy

1.0

 

 

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.  Empiric 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 1/2015; Minor revisions 7/2016

 

 

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