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Difficulty: EasyPreoperative and Postoperative Care

A 60-year-old woman is evaluated on postoperative day 6 following a robotic-assisted total hysterectomy and bilateral salpingo-oophorectomy for endometrial cancer. Her recovery had been uncomplicated until this morning, when she developed a mild fever and sudden-onset shortness of breath. Her temperature is 38.2°C (100.8°F), blood pressure is 110/70 mm Hg, pulse is 112/min, and respirations are 24/min. Pulse oximetry shows an oxygen saturation of 92% on room air. Physical examination reveals clear breath sounds bilaterally. The abdominal surgical incisions are clean, dry, and intact with no surrounding erythema. Her right calf appears mildly swollen and is tender to palpation compared to the left. Which of the following are the most appropriate next steps in the management of this patient? (Select two)

  1. Computed tomography pulmonary angiographyAnswer
  2. Lower extremity venous duplex ultrasonographyAnswer
  3. C
    Administration of empiric intravenous piperacillin-tazobactam
  4. D
    Bedside opening and exploration of the surgical incisions
  5. E
    Instruction on incentive spirometry and deep breathing exercises

Answer

The most appropriate next steps are computed tomography pulmonary angiography and lower extremity venous duplex ultrasonography.
The correct steps are computed tomography pulmonary angiography and lower extremity venous duplex ultrasonography. This patient's presentation of sudden-onset dyspnea, tachycardia, hypoxia, and unilateral calf swelling on postoperative day 6 is highly suspicious for a deep venous thrombosis (DVT) that has progressed to a pulmonary embolism (PE). A low-grade fever is also a common manifestation of venous thromboembolism due to the body's systemic inflammatory response to tissue ischemia and necrosis. Computed tomography pulmonary angiography (CTPA) is the diagnostic test of choice to evaluate for PE, and lower extremity venous duplex ultrasonography is the most appropriate initial test to confirm the presence of a DVT. Identifying the clot is essential to guide subsequent therapeutic anticoagulation.

Step-by-Step Solution

1
Analyze the patient's postoperative timeline and clinical presentation.
The patient developed sudden-onset dyspnea, tachycardia, hypoxia, a mild fever, and unilateral calf swelling on postoperative day 6.
Establishing the postoperative day and recognizing the classic signs of DVT and PE is critical for diagnosis.
2
Determine the appropriate diagnostic workup for the suspected etiology.
Order computed tomography pulmonary angiography (CTPA) for the suspected pulmonary embolism and a lower extremity venous duplex ultrasound for the suspected DVT.
These are the gold standard, non-invasive imaging modalities to confirm venous thromboembolism before committing to long-term therapeutic anticoagulation.

Key Concept

Venous thromboembolism (DVT and PE) classically presents around postoperative days 5 to 7. Sudden-onset shortness of breath, tachycardia, hypoxia, and unilateral calf swelling require immediate diagnostic evaluation with CT pulmonary angiography and lower extremity venous duplex ultrasonography. Low-grade fever is a common systemic inflammatory response to VTE.
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Preoperative and Postoperative Care

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