Sudden breathlessness on the surgical ward
A 68-year-old woman is day 6 after a hemicolectomy. She becomes acutely breathless with pleuritic chest pain. Respiratory rate 28, heart rate 118, blood pressure 108/70, saturations 89% on air, chest clear.
Questions & answers
Q1 What is the differential for postoperative breathlessness on day 6?
Pulmonary embolism, pneumonia and atelectasis, fluid overload or heart failure, myocardial infarction, anastomotic leak with sepsis, and pneumothorax after central line insertion.
Q2 How does the Wells score change your investigation?
A likely score (>4) goes straight to CT pulmonary angiography with interim anticoagulation. An unlikely score is triaged by D-dimer: a negative result excludes PE, a positive one leads to CTPA. D-dimer is unhelpful in the early postoperative period because it is almost always raised.
Q3 Outline immediate management.
Oxygen to target saturation, analgesia and cautious fluids. Therapeutic low-molecular-weight heparin unless bleeding risk forbids it, balanced against recent surgery. Massive PE with haemodynamic instability is treated with systemic thrombolysis, or catheter-directed therapy or embolectomy when thrombolysis is contraindicated after recent laparotomy.
Q4 What thromboprophylaxis should she have had?
Risk assessment on admission, graduated compression stockings and intermittent pneumatic compression, early mobilisation, and low-molecular-weight heparin. Extended prophylaxis for 28 days is recommended after major abdominal or pelvic cancer surgery.
References
- ESC 2019 Guidelines on the diagnosis and management of acute pulmonary embolism.
- NICE NG158: Venous thromboembolic diseases.