CareStandard.com‎ > ‎

PE


2013SL
- MC cause of death following bariatric surgery ? PE
- What is the percentage of hospital deaths attributed to PE ? 16%
- But, PE is suspected < 1/3 of the time prior to death.
- Risk Factors - Virchow's triad - stasis, hyper coagulability, endothelial injury
- Modified Well's criteria >= 6 - high probability - see below.
The negative predictive value of the high-sensitivity d-dimer assay is about 94%.
- DX - in a low probability patient DD < 500 with Well's < 2 rules out PE.
Initiate:
- TX: LMWH 80U/kg push then 25000U/500ml 18U/kg/hr < 70 15 > 70 + Warfarin,
Bridge:
- TX LMWH + Warfarin - start W on day 1, bridge 'til INR 2-3 for 2 days. (UpToDate)
- TX LMWH + Warfarin - start W on day 1, bridge 'til INR 2-3 for 24 hrs if at least 5 days. (ACCP)
- TX LMWH - can also be used at 1 mg/kg BID. REF
Alternatives to LMWH:
- TX LMWH vs UFH  LMWH - reduced bleeds, > bioavail, lower risk of HIT, no monitoring
- TX LMWH vs Rivaroxaban - R as efficacious, R - fewer bleeds
- TX LMWH vs Fondaparinux (See definitions below).
- TX 2012 ACCP Guidelines - either parenteral or Rivaroxaban for DVT or PE.
Continue treatment with:
- TX Compression stockings (PTS) started w/in 1 month, anti-coagulate 3-6 months.
 
AAFP
DX: A common approach is to use a validated prediction rule for risk stratification, screen with d-dimer assay as appropriate, and if necessary, perform the appropriate imaging studies to confirm or exclude VTE. This article reviews the diagnosis of pulmonary embolism and DVT. REF

Modified Well's Criteria for PE risk

Sx: 3
No alternative dx: 3
Tachycardia: 1.5
Immobilization > 3 days or surgery in past 4 weeks: 1.5
Prior hx of DVT or PE: 1.5
Presence of hemoptysis: 1
Presence of malignancy: 1
0-1 Low
2-6 Moderate
6-12 High risk of PE

Marc's acronym: EMBOLUS

E - Evidence or symptoms 3
M - Most likely (no alternative) 3
B - Beats (tachycardia > 100 bpm) 1.5
O - Obtunded (immobilized > 3 days or surgery in past 4 weeks) 1.5
L - Latent 1.5
U - sangUigenous 1
S - Say "malignancy". 1

Definitions:
D-Dimer is a fibrin degradation product, a small protein fragment detectable in the blood after a blood clot is degraded by fibrinolysis. d-dimer assays vary in their sensitivity and specificity. Enzyme-linked immunosorbent assay (ELISA), quantitative rapid ELISA, and advanced turbidimetric d-dimer determinations are more than 95 percent sensitive for VTE.

Factor Xa inhibitors - similar to LMWH
- Rivaroxaban (Xarelto)
- Fondaparinux (Arixtra) 
-- lower HIT risk than LMWH, fewer bleeds
-- can be used in the setting of HIT - no PF4 affinity
-- renal excretion - can't be used in renal insufficiency
Comments