How aggressive on treating Hemodynamically stable PE

[Cadet133]

In a patient say on 4L of O2 with signifiacnt tachycardia but no evidence of RT ventricular strain who has significant DVT with Rt sided PE. How long do you usually keep them on IV Lovenox before you consider switching to Xarelto (Im not referring to bridging as no need for bridge)

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[DrMetal]

A real 4L requirement? Or nursing just cranking up the O2 to make themselves happy? DC the O2, see what happens. What was the level of the PE? How tachy? (cant let a guy go home if HR 160 bpm).

 

[jdh71]

In a patient say on 4L of O2 with signifiacnt tachycardia but no evidence of RT ventricular strain who has significant DVT with Rt sided PE. How long do you usually keep them on IV Lovenox before you consider switching to Xarelto (Im not referring to bridging as no need for bridge)

Pretty much they can go on it immediately

 

[NITRAS]

IV Lovenox?

 

[TheTruckGuy]

Probably means IV heparin?

I'd say it depends on the level of the PE and the patient's age and what caused the PE/DVT. Even without heart strain, if they are large PEs, I'd keep on heparin for a day or two? At least until tachycardia and O2 requirement subside (assuming O2 requirement is real). If no real O2 requirement, and tachycardia subsides quickly, then just put on xarelto maybe 24 hours prior to planned discharge?

But I'm not an internist or hospitalist. Heck, I've only completed PGY1 in EM and haven't done any "real medicine" in over a year.

 

[gulmohr]

Absence of right heart strain (on imaging I assume) implies a low-risk submassive at worst. Would switch them to a DOAC sooner rather than later as @jdh71 mentioned. Would also explore other causes of tachycardia/hypoxia - do they have underlying lung disease, for example?

 

[jdh71]

Absence of right heart strain (on imaging I assume) implies a low-risk submassive at worst. Would switch them to a DOAC sooner rather than later as @jdh71 mentioned. Would also explore other causes of tachycardia/hypoxia - do they have underlying lung disease, for example?

you know depending on where the clot is you may have enough relative loss of Q that your V/Q is easily off enough to give some hypoxemia. I’m often amazed by how clot burden for instance often doesn’t correlate well to objective vital signs findings and symptoms. I wouldn’t work up any additional anything for the hypoxia. NOAC. O2 for home. Discharge with f/u PCP.

 

[aafisahar]

Heparin sucks, takes forever to get therapeutic, has lapses for hours at a time, and tethers patients to IV poles. I'd do lovenox until there's no chance of procedures (filter, catheter directed thrombolytics) then switch to DOACs of choice.

 

[gutonc]

Planning a procedure? Can he swallow pills?

If no and yes, do it yesterday. There's nothing magical about heparin in this scenario.

 

[Cadet133]

So do you guys typically wait for patient to wean off o2 before DC? or do you just send them home on o2?

 

[aafisahar]

So do you guys typically wait for patient to wean off o2 before DC? or do you just send them home on o2?

Depends on how much and comorbidities. Sometimes, you're going to need oxygen for those PEs for a year months.

 

[jdh71]

So do you guys typically wait for patient to wean off o2 before DC? or do you just send them home on o2?

nah

PCP can stop it

 

[CatFactorial]

Heparin sucks, takes forever to get therapeutic, has lapses for hours at a time, and tethers patients to IV poles. I'd do lovenox until there's no chance of procedures (filter, catheter directed thrombolytics) then switch to DOACs of choice.

Agree with this but some considerations. Warfarin, lmwh best in APS

If a cancer patient some DOACs are better than others (rivaroxaban and Edoxaban are recommended). Also if gastric bypass patients apixaban might be indicated but in an off label way

 

[gutonc]

Agree with this but some considerations. Warfarin, lmwh best in APS

True. But nobody is talking about APS. We're talking about transitioning a typical, stable PE to outpatient therapy and getting them the F out of the hospital...so there's room for your transplant patients, who actually need that bed.

 

[mercaptovizadeh]

How much leg clot burden would prompt you guys to get IR to take a look at the patient for the rotorooter? I'm surprised how much has changed in just a few years, I do not recall in residency sending people home on O2 for an acute PE...

 

[jdh71]

How much leg clot burden would prompt you guys to get IR to take a look at the patient for the rotorooter? I'm surprised how much has changed in just a few years, I do not recall in residency sending people home on O2 for an acute PE...

I don’t know. The whole leg? Painful. Potential for vascular compromise. And I’d ask VASCULAR to look at it first. The clinicians not the radiologists need to be making these calls.

 

[mercaptovizadeh]

I don’t know. The whole leg? Painful. Potential for vascular compromise. And I’d ask VASCULAR to look at it first. The clinicians not the radiologists need to be making these calls.

OK, yeah that's what I saw in residency, 2 cases, I recall the lady having a leg that was swollen like a tree trunk and hurt like hell.