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11/1/2014

Evaluation of Dyspnea and Management of Pulmonary Embolism after Surgery

The differential diagnosis for dyspnea after gynecologic surgery includes atelectasis, pneumonia, and pulmonary thromboembolism (PTE).  Atelectasis, the most common cause, occurs in 15-20% of patients after abdominal surgery.  It usually results from shallow breathing due to postoperative pain and immobility. 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 includes a chest radiograph to investigate for an infiltrate.  Management of pneumonia includes   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, hemoptysis, and/or cough are the most common symptoms. Hemodynamic instability may also occur.  

Clinical symptoms of PTE are nonspecific.  An assessment tool, such as the modified Wells criteria (Table), may be of benefit.  A score greater than 4.0 (high probability) is considered a positive result (PTE likely).  The Wells Criteria reflects the importance of maintaining a high index of suspicion by assigning 3 points to the absence of another explanation for the dyspnea.   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 of the lower extremities, 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 involves supportive care and anticoagulation.   Hypoxemia requires oxygen supplementation and may require intubation.  Hypotension may occur.  A multidisciplinary approach should be employed as appropriate based on available hospital resources. 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.  It is often stopped after 3-6 months, but should be continued for a longer period of time if other predisposing conditions exist.

Further Reading:

American College of Obstetricians and Gynecologists’ Committee on Practice Bulletins—Gynecology. Prevention of Venous Thromboembolism in Gynecologic Surgery: ACOG Practice Bulletin, Number 232. Obstet Gynecol. 2021 Jul 1;138(1):e1-e15. doi: 10.1097/AOG.0000000000004445. PMID: 34259490.

 

Initial approval January 2015; Revised January 2018; Minor Revision July 2019; Revised March 2021; Reaffirmed & Reference update September 2022; Reaffirmed July 2024.

 

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