Finally, outpatient management of PE is extremely risky and hasn't gained a lot of acceptance. One study involved only 100 patients, and the second study involving more patients (500) was not without its problems. I am aware of one pending lawsuit against an emergency physician and pulmonologist who discharged a PE patient on low-molecular weight heparin and warfarin. The patient subsequently developed a saddle embolus and died. It is going to be hard to defend this case considering outpatient management of PE is not considered the standard of care nationwide. I mention this to caution anyone who is considering this strategy. We admit patients for far less problems.
the crux of that case may come down to the use of low molecular weight heparin. it's fda approved for dvt with or without pe... but its not fda approved for pe without dvt!
do we use lmwh as an inpatient for pe? sure we do. but its not fda approved.
then you get into when the warfarin was started... which you may not actually have to do, if it can be proven that lmwh was given in a setting without dvt.
with that said, what truthfully happens as an inpatient after a pe has been diagnosed? does it make a difference if the patient is on a heparin drip, versus scheduled injections of unfractionated heparin, versus sheduled injections of lmwh? is there something magical about being on a monitor in that situation? is there any reason that it can't be done with home health?
of course it gets into the resources/access available to the patient... provided the patient is stable (there are, after all, patients with pe who aren't significantly hypoxic, without tachycardia, and with no to minimal chest pain). i can get my patient out of the ed here and seen within 4 hours, and run a heparin drip in the comfort of the patients home, and just have the nurse draw labs as though the patient was in the hospital... or just send them over to a sub acute facility out of the ed. but unfortunatley that's not available to everyone. i suppose i should have prefaced my earlier comments with that to give it some context.
so no, every patient with a pe is not appropriate for home treatment. but there are some. the key, to me at least, is identifying which patients are acceptable, and of those, which have the access/resource for it.
if somone dies after a pe has been diagnosed, as long as the treatment itself has been appropriate, it doesn't matter whether the patient is in the hospital or at home. and yes, i've had a patient with a known pe on a heparin drip in the hospital on the step-down unit/dou succumb to their pe.
sometimes patients live because of what we do
sometimes patients die because of what we do
sometimes patients live in spite/despite what we do
sometimes patients die in spite/despite what we do
btw, i'd love to see either of those 2 studies that you were referring to.
