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Difficulty: MediumPreoperative and Postoperative Care

During morning rounds, the rapid response team is called for a patient who suddenly developed severe dyspnea and pleuritic chest discomfort. The patient, a 73-year-old retired teacher, is currently recovering in the orthopedic ward four days after an elective right total hip replacement. She has a history of essential hypertension, mild chronic obstructive pulmonary disease, and diet-controlled type 2 diabetes. Upon arrival, her vital signs are temperature 37.7°C (99.9°F), blood pressure 110/68 mmHg, pulse 122/min, and respirations 28/min. Oxygen saturation is 89% on room air. Physical examination reveals clear breath sounds bilaterally without wheezing or crackles. Jugular venous distension is present. The right calf is visibly swollen, erythematous, and tender to palpation. An electrocardiogram demonstrates sinus tachycardia. Which of the following are the most appropriate immediate steps in managing this patient's condition? (Select all that apply)

  1. Order a computed tomography pulmonary angiogramAnswer
  2. Initiate empiric therapeutic anticoagulationAnswer
  3. C
    Administer intravenous furosemide for suspected fluid overload
  4. D
    Initiate empiric intravenous broad-spectrum antibiotic therapy
  5. E
    Obtain blood and urine cultures as part of a routine fever workup

Answer

The correct immediate steps are to order a computed tomography pulmonary angiogram and to initiate empiric therapeutic anticoagulation.
The correct answers involve confirming the diagnosis of a pulmonary embolism and preventing further thrombus formation. Computed tomography pulmonary angiography is the diagnostic imaging modality of choice for confirming a pulmonary embolism in a hemodynamically stable patient. Additionally, in a patient with a high pretest probability of a pulmonary embolism who is hemodynamically stable, empiric therapeutic anticoagulation should be initiated immediately, even before diagnostic imaging is completed. While the patient had recent surgery, the immediate risk of a fatal pulmonary embolism outweighs the risk of surgical site bleeding, and easily reversible agents (like intravenous unfractionated heparin) are typically preferred in this setting.

Step-by-Step Solution

1
Analyze the patient's vital signs and physical examination findings in the context of her recent surgery.
The patient presents with acute dyspnea, hypoxia, pleuritic chest pain, jugular venous distension, and unilateral calf swelling on postoperative day 4.
Identifying this triad of symptoms in a recently immobilized surgical patient points strongly toward a deep vein thrombosis complicated by a pulmonary embolism.
2
Assess the patient's hemodynamic status.
The patient is hemodynamically stable with a blood pressure of 110/68 mmHg.
Hemodynamic stability dictates the diagnostic and therapeutic algorithm, allowing for transport to the CT scanner rather than requiring bedside echocardiography or empiric thrombolysis.
3
Determine the appropriate immediate diagnostic and therapeutic interventions.
Initiate empiric therapeutic anticoagulation immediately and order a computed tomography pulmonary angiogram.
Empiric anticoagulation prevents further clot propagation while awaiting definitive imaging, which is the standard of care for high-risk, stable patients.

Key Concept

Diagnosis and management of acute pulmonary embolism in the postoperative setting
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Topics

Preoperative and Postoperative Care

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