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Difficulty: MediumPreoperative and Postoperative Care

A physician evaluates a 64-year-old female patient in the emergency department. She presents with sudden-onset right-sided chest pain that worsens with deep inspiration, accompanied by progressive shortness of breath over the past two hours. The patient underwent an uncomplicated right total hip arthroplasty seven days ago and has been recovering at a local rehabilitation facility. Her past medical history is significant for obesity and essential hypertension. Her current temperature is 37.8 C (100.0 F), blood pressure is 112/68 mmHg, pulse is 118/min, and respiratory rate is 26/min. Pulse oximetry shows 89% on room air. Physical examination reveals clear lung fields bilaterally. The right lower extremity demonstrates mild non-pitting edema and tenderness in the calf muscles. An electrocardiogram demonstrates sinus tachycardia. Which of the following are the most appropriate immediate steps in the management of this patient? (Select all that apply)

  1. Initiate an empiric continuous infusion of unfractionated heparinAnswer
  2. Obtain a computed tomography angiogram of the pulmonary arteriesAnswer
  3. C
    Administer intravenous furosemide
  4. D
    Initiate intravenous piperacillin-tazobactam and vancomycin
  5. E
    Obtain blood cultures and a urinalysis before initiating further therapies

Answer

Initiate an empiric continuous infusion of unfractionated heparin AND Obtain a computed tomography angiogram of the pulmonary arteries.
The correct sequence of actions involves both initiating an empiric continuous infusion of unfractionated heparin and obtaining a computed tomography angiogram of the pulmonary arteries. The patient's presentation of sudden-onset pleuritic chest pain, hypoxia, tachycardia, and unilateral calf swelling one week following major pelvic/orthopedic surgery strongly suggests an acute pulmonary embolism (PE). Because she has a high pretest probability for PE (per Wells criteria), clinical guidelines mandate that systemic anticoagulation be initiated immediately—prior to diagnostic imaging—to prevent further thrombus propagation and reduce mortality, provided there are no absolute contraindications. Simultaneously, computed tomography pulmonary angiography (CTPA) should be ordered as it is the most sensitive and specific non-invasive diagnostic test to confirm the presence of a pulmonary embolus.

Step-by-Step Solution

1
Analyze the clinical presentation and timeline.
The patient has sudden pleuritic chest pain, hypoxia, clear lungs, and unilateral leg swelling seven days after major orthopedic surgery.
Identifying the timing and specific combination of symptoms establishes a high clinical suspicion (high pretest probability) for venous thromboembolism (DVT progressing to PE).
2
Determine the need for immediate empiric treatment.
Empiric anticoagulation (e.g., unfractionated heparin) is selected.
In patients with a high pretest probability for acute PE and no contraindications, mortality is reduced by starting systemic anticoagulation immediately, rather than waiting for diagnostic confirmation.
3
Select the appropriate diagnostic imaging.
Computed tomography angiography (CTA) of the pulmonary arteries is ordered.
CTA is the gold-standard and most appropriate initial imaging test to definitively diagnose a pulmonary embolism in a hemodynamically stable patient with abnormal oxygenation.

Key Concept

Management of acute pulmonary embolism in the postoperative period requires simultaneous empiric systemic anticoagulation and diagnostic confirmation with computed tomography pulmonary angiography in patients with high pretest probability.
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Topics

Preoperative and Postoperative Care

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