andersenpa Posted June 4, 2011 Share Posted June 4, 2011 You, the intrepid on-call surgical PA, are on call once again and settling into the end of your day shift. It is approaching evening when the clinic calls you for an admission. 51 yo M, POD# 11 s/p ascending aortic dissection repair. Recent history shows that he was discharged POD#5, and then returned to the ED 2 days later c/o productive cough. He was treated for PNA and sent home. He came to clinic today for his routine follow up. He says that yesterday he noticed blue discoloration of his toes, on both feet. The nurse specialist who saw him in clinic tells you that the pt is c/o persistent cough, some SOB, as well as the toe discoloration. She is concerned about the constellation of findings and the clinic is arranging an admission for YOU to work up. You take a long slow sip of delicious cafeteria decaf and head over to the hospital to see the pt. What are your thoughts en route to the patient, and what else do you want to know before the vitals/exam/etc…..? To save time: Other PMH: Hyperlipidemia Depression Colonic polyps PSH: Dissection repair as mentioned Rotator cuff SH: Naturopathic physician Married Nonsmoker/nondrinker NKA Meds azithromycin metoprolol lisinopril ASA Oxycodone PRN amiodarone Link to comment Share on other sites More sharing options...
jmj11 Posted June 4, 2011 Share Posted June 4, 2011 Out of my league, but certainly want to see CBC and coag factors, PT PTT serum Fibrinogen etc. First thoughts would be local a. thrombosis at surgical site, but considering the lung symptoms, early DIC with PE and more distal thromboses. I will sit and watch you smarter folks figure it out. Link to comment Share on other sites More sharing options...
jesscbv Posted June 4, 2011 Share Posted June 4, 2011 Was this a Debakey type I or II? In other words, after the repair, was the patient left with residual abdominal aortic dissection? SOB: post-op inflammatory pleural effusion? Discoloration of (bilateral) toes: extension of dissection into abdominal aorta (Type I) with intimal flap restricting iliac flow? Post-op emboli? Check ABI, toe pressures, pedal pulses. I may be way off base, but I'm excited to hear what everyone says! Link to comment Share on other sites More sharing options...
xxbowiexx Posted June 4, 2011 Share Posted June 4, 2011 i was thinking along the line of thrombosis or vascular aneurysm as well, especially considering blue toes. Had it been a long bone, i would consider fat embolism as possible cause. But in this case, DIC with secondary PE seems to fit the picture. On my way to see the patient, i would like to review the surgical notes as well as past H&P, including VS and notes from the time pt was diagnosed with PNA. I would order VS,CBC, full coag panel, EKG, ABI, venous doppler, assess surg. site, CXR. Would you consider D-dimer? it would most likely be high, but if it's not then we can rule out PE. Helical CT if warranted. Out of curiosity, how long has he been taking amiodarone? Link to comment Share on other sites More sharing options...
bradtPA Posted June 4, 2011 Share Posted June 4, 2011 Need a stat CT angiogram of the aorta with runoff to assess the circulation. I usually use an MRA, but in primary care we have time to wait after an abnormal ABI. Also, was the cough misdiagnosed, and this actually a PE, and now he has thrown another clot to the iliacs or higher? Link to comment Share on other sites More sharing options...
medic25 Posted June 4, 2011 Share Posted June 4, 2011 You take a long slow sip of delicious cafeteria decaf and head over to the hospital to see the pt. This is the first major problem I see. Decaf while you're on call? I didn't know such a thing was allowed in the hospital!! :) Link to comment Share on other sites More sharing options...
Moderator ventana Posted June 4, 2011 Moderator Share Posted June 4, 2011 asses pedal pulses and rather toes are warm or cold if cold - have to get pulses - if none palpable then get a doppler - do work up for emergent revascularization vs anticoag?? (what is correct after repair?) What about EKG looking for s1q3t3 and what are sats - thinking PE here unsure if D-dimer is worth it as that is to rule out in low probability cases any green/blue skin elsewhere (amidarone green) Gotta believe based almost 100% on history you gotta get a CTA with run off or head to the specials suite but if strong DP/PT pulses would not have to do this... compare left versus right.... And WTH with decaf... that is not gonna cut it at all Link to comment Share on other sites More sharing options...
andersenpa Posted June 4, 2011 Author Share Posted June 4, 2011 Was this a Debakey type I or II? In other words, after the repair, was the patient left with residual abdominal aortic dissection?SOB: post-op inflammatory pleural effusion? Discoloration of (bilateral) toes: extension of dissection into abdominal aorta (Type I) with intimal flap restricting iliac flow? Post-op emboli? Check ABI, toe pressures, pedal pulses. I may be way off base, but I'm excited to hear what everyone says! Good questions. I'll insert extra information as it comes up. Debakey classification I- entire aorta II- ascending only IIIa- descending thoracic only IIIb- descending thoracoabdominal Stanford classification A- ascending involved B- ascending NOT involved ie stanford doesn't tell you if there is descending dissection; debakey I and II are both stanford A Stanford helps differentiate those that need urgent surgery and those that don't THIS patient had dissection from the aortic valve down to the iliacs (Stanford A, Debakey I) His dissection is repaired and I can tell you he has not had progression of the descending dissection. How about more history first..... Link to comment Share on other sites More sharing options...
andersenpa Posted June 4, 2011 Author Share Posted June 4, 2011 i was thinking along the line of thrombosis or vascular aneurysm as well, especially considering blue toes. Had it been a long bone, i would consider fat embolism as possible cause. But in this case, DIC with secondary PE seems to fit the picture. On my way to see the patient, i would like to review the surgical notes as well as past H&P, including VS and notes from the time pt was diagnosed with PNA. I would order VS,CBC, full coag panel, EKG, ABI, venous doppler, assess surg. site, CXR. Would you consider D-dimer? it would most likely be high, but if it's not then we can rule out PE. Helical CT if warranted. Out of curiosity, how long has he been taking amiodarone? Op note- replacement of the ascending aorta with dacron tube graft, closure of intimal flap (reapproximating dissected layers with and incorporating this into anastamosis with ascending graft). Patient placed on cardiopulmonary bypass through cannulation of the R femoral artery. Patient developed a hematoma of the R groin after the line was removed. Rest of H&P noncontributory. Seen in ED for PNA BP 157/82 P 94, reg RR 20, unlabored 94% on RA Temp 36.9 WBC 17k Hct 27 (25 at discharge 2 days prior) Plat 49k Na 129 HCO3 16 7.53/23/104/22 coags Nl D Dimer and CT not done at that time CXR bibasilar haziness, retrocardiac density He has been on amio since POD#1 Link to comment Share on other sites More sharing options...
andersenpa Posted June 4, 2011 Author Share Posted June 4, 2011 Need a stat CT angiogram of the aorta with runoff to assess the circulation. I usually use an MRA, but in primary care we have time to wait after an abnormal ABI. Also, was the cough misdiagnosed, and this actually a PE, and now he has thrown another clot to the iliacs or higher? What do you mean by thrown a clot- from where/to where? Link to comment Share on other sites More sharing options...
andersenpa Posted June 4, 2011 Author Share Posted June 4, 2011 This is the first major problem I see. Decaf while you're on call? I didn't know such a thing was allowed in the hospital!! :) I knew one of you guys would notice that. My norepinephrine levels are high enough as it is. Link to comment Share on other sites More sharing options...
andersenpa Posted June 4, 2011 Author Share Posted June 4, 2011 asses pedal pulses and rather toes are warm or cold if cold - have to get pulses - if none palpable then get a doppler - do work up for emergent revascularization vs anticoag?? (what is correct after repair?) What about EKG looking for s1q3t3 and what are sats - thinking PE here unsure if D-dimer is worth it as that is to rule out in low probability cases any green/blue skin elsewhere (amidarone green) Gotta believe based almost 100% on history you gotta get a CTA with run off or head to the specials suite but if strong DP/PT pulses would not have to do this... compare left versus right.... And WTH with decaf... that is not gonna cut it at all As you walk to the hospital, you mull over the grief your coworkers are giving you for drinking decaf. To each his own. Hmmph. You arrive at the bedside. The patient is lying in bed, comfortable, no distress. He tells you basically the same story your colleague in clinic told you. He denies SOB or CP. His only complaint is painful toes, R>L. RR 16. sat 99% on 2L. HR 79. BP 132/79. L chest base diminished. Reg pulse. incisions all OK, no infectious concerns. arm pulses OK. strong PT/DPs bilat, equal. Feet warm to forefoot. Toes dusky and blue bilat, R worse than L. Cool toes, equally bilat. Most affected is R middle toe. All toes tender to palpation. BLE swelling, R>L. EKG normal. CXR same as ED CXR report. labs WBC 20.7, 77% shift Hct 23 Plt 51 Na 121 K 4.6 HCO3 21 Cr 0.7 Ca 7.8 AP 161 coags Nl Link to comment Share on other sites More sharing options...
xxbowiexx Posted June 4, 2011 Share Posted June 4, 2011 If coag is normal, then DIC is less likely. An WBC of 20.7 along with 77% shift and a hazy CXR indicates bacterial PNA, one that azithromycin isn't doing enough to help. Hospital acquire PNA perhaps? HCT and PLT is awfully low, which may reflect the possible risk of thrombotic event thus lead to the blue toes. Further history and exams doesn't support PE as much as i thought. For some reason, i keep thinking that amiodarone is the culprit. It may induce ITP or TTP....but the kidney function seems to be normal which makes it less likely. The sodium is quite low, most likely due to SIADH secondary to postoperative. It could be due to dilution from IVF but less likely as the pt was discharged home and came back being hyponatremic. Link to comment Share on other sites More sharing options...
bradtPA Posted June 4, 2011 Share Posted June 4, 2011 What do you mean by thrown a clot- from where/to where? I am probably way off base, but my thinking was a clot formed at the area of the graft breaking free, and impeding circulation downstream somewhere such as the bifurcation before the iliacs. With the history given now that the circulation appears intact except for the feet, that is would be the area to focus on now, however. Interesting case as usual, presented by a top CT PA. I am much better at treating DM, and sending you the vascular cases after I work them up for repair:). Link to comment Share on other sites More sharing options...
andersenpa Posted June 4, 2011 Author Share Posted June 4, 2011 I am probably way off base, but my thinking was a clot formed at the area of the graft breaking free, and impeding circulation downstream somewhere such as the bifurcation before the iliacs. With the history given now that the circulation appears intact except for the feet, that is would be the area to focus on now, however. Interesting case as usual, presented by a top CT PA. I am much better at treating DM, and sending you the vascular cases after I work them up for repair:). The presentation suggests both arterial and venous side problems....the hint in this dx is tying them together. Link to comment Share on other sites More sharing options...
jesscbv Posted June 4, 2011 Share Posted June 4, 2011 AV fistula secondary to R SFA cannulation? Link to comment Share on other sites More sharing options...
cinntsp Posted June 5, 2011 Share Posted June 5, 2011 Glucose? Amylase? Link to comment Share on other sites More sharing options...
andersenpa Posted June 5, 2011 Author Share Posted June 5, 2011 AV fistula secondary to R SFA cannulation? No fistula. (cannulation is of the CFA, above the bifurcation) But that means you think a clot is traveling from somewhere. Link to comment Share on other sites More sharing options...
andersenpa Posted June 5, 2011 Author Share Posted June 5, 2011 Glucose? Amylase? Glc 119. Amy nl. The clue to this one is in the labs.....and knowing what goes on during a dissection repair. Recall the patient was put on cardiopulmonary bypass..... Link to comment Share on other sites More sharing options...
jmj11 Posted June 5, 2011 Share Posted June 5, 2011 Glc 119.Amy nl. The clue to this one is in the labs.....and knowing what goes on during a dissection repair. Recall the patient was put on cardiopulmonary bypass..... Was the patient given warfarin during bypass? Link to comment Share on other sites More sharing options...
merseur Posted June 5, 2011 Share Posted June 5, 2011 Usually patients are fully heparinized during bypass surgery. What is the heparin Ab status? Possible some degree of femoral artery stenosis from the bypass. BLE edema, patient is retaining fluid. Low Hct, post op anemia vs. hemodilution Low sodium, poss hemodilution PNA, may affect O2 perfusion Link to comment Share on other sites More sharing options...
rcdavis Posted June 5, 2011 Share Posted June 5, 2011 And the answer is in the hx Link to comment Share on other sites More sharing options...
deborah212 Posted June 5, 2011 Share Posted June 5, 2011 After thinking about your hint and what goes on during bypass (heparinization), this sounds like HITT, what merseur alluded to. How about a platelet trend from the prior admission? I would send a PF4 and start anticoagulation with a non-heparin product. Link to comment Share on other sites More sharing options...
xxbowiexx Posted June 5, 2011 Share Posted June 5, 2011 i agreed with HITT, considering drops in platelets 5-6 days after administration. Link to comment Share on other sites More sharing options...
andersenpa Posted June 5, 2011 Author Share Posted June 5, 2011 Was the patient given warfarin during bypass? Usually patients are fully heparinized during bypass surgery. What is the heparin Ab status? Possible some degree of femoral artery stenosis from the bypass. BLE edema, patient is retaining fluid. Low Hct, post op anemia vs. hemodilution Low sodium, poss hemodilution PNA, may affect O2 perfusion Heparin is given to essentially all patients undergoing cardiopulmonary bypass. The bypass circuit (tubing) produces and strong inflammatory and coagulation response. Normal heparin dose is 300 u/kg (compared to ~80u/kg for usual DVT/ACS tx). HIGH dose. i agreed with HITT, considering drops in platelets 5-6 days after administration. After thinking about your hint and what goes on during bypass (heparinization), this sounds like HITT, what merseur alluded to. How about a platelet trend from the prior admission? I would send a PF4 and start anticoagulation with a non-heparin product. Good work guys. This is type II HIT (aka HITT, or HIT with thrombosis, aka white clot syndrome) Type I HIT is a non-immune mediated process with lesser fall in plat counts and no thrombosis risk. The reason we didn't chase the PE workup was because we suspected HITT on admission. We started tx empirically and found the heparin induced antiplatelet antibody positive in ~48 hrs. Tx includes stopping all heparin products, anticoagulation with (in most cases) a direct thrombin inhibitor (we use argatroban), and subsequent warfarin once the platelet count rises to 100-150k. I suspect the hematoma he had in the R groin impaired drainage/cause relative stasis and led the the development of the DVT on that side. Link to comment Share on other sites More sharing options...
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