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    Post Operative Pulmonary Embolism: Case-Control Studies

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    ifan zulfantri
    1. Pulmonary embolism (PE) is potentially fatal but often underdiagnosed or overdiagnosed. 2. The case report describes a 62-year old woman who developed sudden dyspnea after cholecystectomy and was ultimately diagnosed with extensive PE. 3. PE results from obstruction of the pulmonary arteries, usually from deep vein thrombosis, and causes respiratory and hemodynamic complications if large or numerous emboli are present.

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    Post Operative Pulmonary Embolism: Case-Control Studies

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    ifan zulfantri
    15 views24 pages
    1. Pulmonary embolism (PE) is potentially fatal but often underdiagnosed or overdiagnosed. 2. The case report describes a 62-year old woman who developed sudden dyspnea after cholecystectomy and was ultimately diagnosed with extensive PE. 3. PE results from obstruction of the pulmonary arteries, usually from deep vein thrombosis, and causes respiratory and hemodynamic complications if large or numerous emboli are present.

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    Emboli paru

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    Post Operative Pulmonary Embolism-3

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    1. Pulmonary embolism (PE) is potentially fatal but often underdiagnosed or overdiagnosed. 2. The case report describes a 62-year old woman who developed sudden dyspnea after cholecystectomy and was ultimately diagnosed with extensive PE. 3. PE results from obstruction of the pulmonary arteries, usually from deep vein thrombosis, and causes respiratory and hemodynamic complications if large or numerous emboli are present.

    Copyright:

    © All Rights Reserved
    Download as PPT, PDF, TXT or read online from Scribd
    Download as ppt, pdf, or txt
    15 views24 pages

    Post Operative Pulmonary Embolism: Case-Control Studies

    Uploaded by

    ifan zulfantri
    1. Pulmonary embolism (PE) is potentially fatal but often underdiagnosed or overdiagnosed. 2. The case report describes a 62-year old woman who developed sudden dyspnea after cholecystectomy and was ultimately diagnosed with extensive PE. 3. PE results from obstruction of the pulmonary arteries, usually from deep vein thrombosis, and causes respiratory and hemodynamic complications if large or numerous emboli are present.

    Copyright:

    © All Rights Reserved
    Download as PPT, PDF, TXT or read online from Scribd
    Download as ppt, pdf, or txt
    of 24

    CASE-CONTROL STUDIES:

    POST OPERATIVE
    PULMONARY EMBOLISM
    By: R.S. Parhusip
    &
    Bintang Sinaga
    Bagian Paru-ICU Dewasa
    RSUP. H. ADAM MALIK MEDAN/
    FAKULTAS KEDOKTERAN-USU
    Respina Jakarta September 17 2003
    Introduction
    • Pulmonary Embolism (PE)  potentially fatal
    • Under-diagnosed  >>
    • Over-diagnosed
    autopsy
    • Incidents are different in every country 
    accuracy of diagnostic
    • In US: 500,000 PE patients/years, mortality
    rate  10%
    Case Report
    • Aug, 02. 2001.
    • 1.30 pm: female, age 62 yrs, developed sudden
    dyspnea. She had cholecystectomy on 31 July
    2001(post-operated).
    • Examination: Sensorium: CM, tachypnea,
    tachycardia and normal blood pressure. Varicose
    veins (+) at lower leg.
    • History of dyspnea (-), angina pectoris (-), smoking
    (-). Previous treadmill: ST depression in lead V4 &
    V5. She had controlled diabetes & hypertension.
    • 1:55 pm.
    Chest X-Ray
    • 4:22 pm
    CT Angiogram Pulmonary
    Artery
    • extensive PE primarily at the left
    pulmonary artery and its lower lobe branch.
    Also in right pulmonary artery, Atelectasis /
    consolidation in right lower lobe
    • 4:25 pm :distress with hypoxia (Pa O2 : 36 mm
    Hg)
    • 5.15 pm : she was operated (median sternotomy)-
    > right ventricle dilatation --> Cardiopulmonary
    by pass, embolectomy. Post op: good
    hemodynamic, impaired contractility and severe
    dilated of right ventricle
    • Heparin-warfarin (INR) and stocking compression
    • Aug 03 2001:
    X-Ray Images
    • Aug 04 2001:
    • Aug 04 2001: she was sent out of the ICU.
    • Aug 06 2001: ultrasound echo doppler  thrombosis in the
    posterior tibial vein.

    • Aug 08 2001: she was discharged from hospital and consumed


    warfarin 2.5 mg for at least 6 month.
    • Sept 03 2001: Sudden dyspnea, INR was 5.9 although with 2.5
    mg warfarin--> pericardial hematothorax effusion with
    tamponade+ pleural effusion --> pericardial drainage -->
    • Sept 04 2001:open surgery (repeated operation)
    • Jan 09 2002:echo:thrombus (+) --> warfarin was continued
    Discussion
    • PE: under & over diagnosed  diagnosed and
    therapeutic problem.
    • PE: obstruction of pulmonary artery usually from DVT.
    Others: pelvic, renal, upper extremity vein, superior
    vena cava and right heart.
    • Thrombus >>
    Other substances: air, amniotic fluid, fat, foreign bodies
    (drug abuser), parasite eggs, septic emboli, tumor cells.
    • Factors: Virchow’s Triad
    – venous static  immobility (post op, stroke, etc)
    – injury to the intima  trauma, operation
    – change in blood coagulation  medication, disease,
    inherited.
    • Respiratory:  dead space, shunting  hypoxia, 
    pulmonary resistance, airway resistance,
    hyperventilation, loss of surfactant   compliance 
    atelectasis.
    • Hemodynamic:  pulmonary resistance   afterload
    right ventricle  right vent. Failure
    • Sign and symptom : size, location, number
    and cardiopulmonary status.
    • Symptom from non specific until severe
    dyspnea collapse or shock  dyspnea,
    chest pain, cough, hemoptisis, tachypnu,
    rales, tachycardi, P2 
    • DVT: swollen, tenderness, palp trombus,
    varicose vein, pain, redness
    • Symptoms and Signs Of PE
    Diagnostic
    Symptoms: - Dyspnea 80%
    - Pleuritic pain 70
    - Apprenhension 60
    - Cough 50
    - Symtomps Of DVT 35
    - Hemoptysis 25
    - Central Chest Pain 10
    - Palpitations 10
    - Syncope 5
    Signs : - Tachypnea 90
    - Fever 50
    - Tachycardia 50
    - Increased P2 50
    - Sign of DVT 33
    - Shock 5
    •ABGA: Resp alk, PaO2 , hypocapnia. Important
    in high risk patient (post operative) where other
    respiratory condition can be ruled out and PaO2 is
    low.
    •D dimer:
    –negative predictive value 95%: < 500 mg/l
    –low specificity
    •ECG:
    –tachycardy, S&T wave non specific
    –P pulmonale, RVH, RAD, RBBB
    –Not specific
    • X-ray:
    – normal in 12% PE
    – atelectasis, infiltration parenchym, pleural effusion,
    elevated diaphragm
    – oligemia
    – very useful if X-ray normal in hypoxia patient
    • V/Q scan (PIOPED Criteria):
    – diagnostic in normal or near normal or high probability
    • Ultrasound of DVT: sensitivity 80-90 % in
    symptomatic patients.
    • Pulmonary angiography:
    – gold standard
    – cut off
    – detection 1-2 mm emboli
    – save procedure
    – high risk: pulmonary hypertension, RVF
    • Spiral chest CT scan:
    – sensitivity: 99% in main, lobar & segment
    artery
    – can not detect emboli at sub-segmental but
    frequency < 5%
    – filling defect
    • Echocardiography: dysfunction of RV
    • Management:
    – Medication:
    • trombolitic -> Faster thrombus resolution, indication, complication
    >>
    • anticoagulation
    – unfractionated heparin -> not directly lysis the thrombus,
    infusion, aPTT
    – fractionated heparin -> bioavailibility >, SC, aPTT (-), effective
    as UFH
    – oral anticoagulation -> warfarin, INR 2,0 - 3,0
    – Operative: embolectomy
    vena cava inferior filter
    Embolectomy:
    • massive PE : hipotension, oliguri, refracter hypoxia
    • >50% obstruction, Pa O2 < 60 mm Hg, Systolic < 90 mm Hg, urin <
    20 ml/h
    • life threatening
    • failure to thrombolytic in 3 hours or contraindication to thrombolytic
    • study : heparin, thrombolytic, embolectomy (-)
    Prevention:
    • heparin prophylaxis - before operation or in special medical
    condition
    • stocking compression
    CONCLUSION
    • PE: potentially fatal
    • PE: missdiagnosed
    • PE: diagnostic, therapy, prevention

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