How would you manage an intermediate-risk segmental PE that is transiently provoked after a knee surgery?
How would you manage an intermediate-risk segmental PE that is transiently provoked after a knee surgery?
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Segmental suggests small PE and prob intermediate-low risk. But still look at vitals, RV/LV ratio, and clot burden. Again, clot sounds small (no lobar, main PA or saddle, but look for contrast-reflux into IVC/liver. Try to look at RV FUNCTION by echo if possible, and echo also allows ruling out a clot in transit. Prob will be anticoagulation alone, unless any of the above parameters are concerning. For example, if HR was 120/min, and pt requires O2 would discuss catheter embolectomy. That would ...
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Full anticoagulation of very recent (1 to 5 days) total knee replacement, for example, is high-risk for bleeding complications of a surgery that already takes 3 to 6 months to recover from without complications.
Instead, start intravenous (IV) unfractionated heparin (UFH) drip without bolus, maybe half-dose (9 U/kg actual body weight/hr), and watch the surgical site. Dial the drip down if the knee swells or bleeds, dial up very, very slowly if not, aiming for an anti-Xa level of 0.3 to 0....
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