To US or not to US

[streetdoc]

---

Members do not see this ad.

I came across this situation last night and was hoping for some outside input as to if the pt needs an US/DVT rule out or not.

Pt is 65ish F with history of metastatic cancer and PEs. Has an IVC filter in place. On coumadin but last INR (the day before) was 1.5 and she has not adjusted her dosing yet. She had a work up at local urgent care where a ddimer was obtained (I'm really not sure why) and it was elevated. they sent her to the ER for a CT chest. that simply was not going to happen not to mention she has a contrast allergy which is anaphylaxis. Anyway, the family was quite concerned she had another clot. Now, with the subtherapeutic INR and her history it certainly is possible, however she already has a filter.

So, would you US her legs to look for clot? Is that really going to change management?
Thanks for input, I'm just rehashing a busy night and trying to make sure I am doing the right thing.

streetdoc

 

[EMCC]

Maybe I missed it, but why exactly was the patient in the ED? I realize she had an elevated D dimer, but what were her complaints?

Assuming Leg pain/edema--yes, I would U/S her. Below the knee, get the coumadin therapeutic (I know, not our job). Above the knee, she needs to get therapeutic on her coumadin.

Assuming chest pain--yes, she needs a CT chest (V/Q perhaps?). Remember, a filter does reduce your risk of a saddle embolus, but does not reduce your risk of a PE. In fact, Virchow's triad stipulates that you are at higher risk for PE based on the presence of a filter...

Again, the coumadin needs to become therapeutic. If she continues to develop clots despite a therapeutic INR, then she will probably need to be switched to Pradaxa (shudder), Argatroban, Arixtra, or Lovenox.

 

[streetdoc]

As far as exam, she had LE edema, basically symmetric. no chest pain/sob.

Originally she went to urgent care for confusion-long standing episodes, been workup in pt and out pt. alert/ oriented for me, viatals were normal. hx of UTIs and, yep, she had a uti per urgent care UA. urgent care started keflex and then sent her to my ED because of the lab value.

i had a long discussion with the family about working up the confusion, but they stated this is her typical uti symptom so i reviewed the outside labs (normal), ua, CXR. and they were happy with leaving it at that.

I mainly addressed the "they told me i have a clot again" issue. i discussed the whole "this is just a lab value" but they were pretty worked up so I figuered the US was a good bet. If negative, great, lets up that coumadin NOW like you were told to do yesterday. If positive, I was going to see about covering her with lovenox and setting up out pt injections and inr checks, etc. So i did the US even though radiology questioned my reasoning which made me question my reasoning. seemed reasonable to me in the middle of a busy night anyway 🙂

streetdoc

 

[Greenbbs]

Maybe I missed it, but why exactly was the patient in the ED? I realize she had an elevated D dimer, but what were her complaints?

Assuming Leg pain/edema--yes, I would U/S her. Below the knee, get the coumadin therapeutic (I know, not our job). Above the knee, she needs to get therapeutic on her coumadin.

Assuming chest pain--yes, she needs a CT chest (V/Q perhaps?). Remember, a filter does reduce your risk of a saddle embolus, but does not reduce your risk of a PE. In fact, Virchow's triad stipulates that you are at higher risk for PE based on the presence of a filter...

Again, the coumadin needs to become therapeutic. If she continues to develop clots despite a therapeutic INR, then she will probably need to be switched to Pradaxa (shudder), Argatroban, Arixtra, or Lovenox.

Ick. Don't mention that "P" word. I've already had a guy on that with a big GI bleed. Terrible drug.

 

[EMCC]

What I don't get with the "P word" is how a twice a day drug is supposed to be not inferior to a once a day (at night) drug??? Because we don't check how thick the blood is? Just doesn't make sense to me...

I have seen 4 head bleeds and one GI bleed. I am tempted to start consulting hospice straight away on Pradaxa bleeds. 🙂

Gotta love a thinner with no possibility of reversal. Oh, and who the heck knows how to interpret the lab test for pradaxa monitoring?? (can't remember the test off the top of my head)

 

[xaelia]

Gotta love a thinner with no possibility of reversal.

PCCs.

"Hemodialysis".

:\

 

[crewmaster1]

Why do you care if she has a DVT or a PE? She has cancer and already has PEs, so she needs to be appropriately anticoagulated regardless of the results of your test. You said she is already on warfarin, but subtherapeutic. So supplement with LMW heparin while you titrate up her warfarin. Unless you think she has a massive PE and if present you will give lytics to reduce RH strain, pulm HTN, etc....an duplex U/S sure isn't going to make the diagnosis of massive PE. If anything, consider an echo to look for indications for lytics, but in an asymptomatic patient that is able to walk from minor care, she doesn't need lytics. The general theme is: don't order tests that aren't going to change your management!

 

[crewmaster1]

I mainly addressed the "they told me i have a clot again" issue. i discussed the whole "this is just a lab value" but they were pretty worked up so I figuered the US was a good bet. If negative, great, lets up that coumadin NOW like you were told to do yesterday. If positive, I was going to see about covering her with lovenox and setting up out pt injections and inr checks, etc. So i did the US even though radiology questioned my reasoning which made me question my reasoning. seemed reasonable to me in the middle of a busy night anyway 🙂

streetdoc

So in a patient with metastatic cancer and known PEs you were cool sending her out subtherapeutic? Maybe after a good discussion of the risks and benefits of adding temporary LMWH. But an INR of 1.5 is nearly normal and I tend not to like normal INRs in people with PEs and cancer.

Duplex ultrasounds are also great for diagnosing DVTs, but I'm not sure there is great evidence that no DVT means no PE. After all the DVT, or at least part of it, had to leave the leg to get to the lung.

 

[leviathan]

So in a patient with metastatic cancer and known PEs you were cool sending her out subtherapeutic? Maybe after a good discussion of the risks and benefits of adding temporary LMWH. But an INR of 1.5 is nearly normal and I tend not to like normal INRs in people with PEs and cancer.

Duplex ultrasounds are also great for diagnosing DVTs, but I'm not sure there is great evidence that no DVT means no PE. After all the DVT, or at least part of it, had to leave the leg to get to the lung.

Isn't it only 1/3 of PEs have a DVT present as well?

 

[WilcoWorld]

The statistic I'm familiar with is that 80% of PE's have a DVT on US (NEJM, Vol. 358, pg. 1037).

Firstly, I understand the OP's predicament of having a family in your ED that was sent in by a PCP for an non-indicated work-up. Who are they going to believe, the PCP that they know, or you the "ER doc"? So what I would actually do in this situation has a lot to do with circumstance.

Academically/medically speaking: Patients with a known PE who have stable vitals and no new symptoms DO NOT need a work-up for PE or DVT. They do, however, need to be therapeutic. If they do have new/worsening symptoms or evidence of increased clot burden then it is reasonable to do a work-up, since some people do not respond to coumadin as we would like.

In this case, it sounds like we are working up confusion and an elevated d-dimer. Well, I don't care about the dimer. As for the confusion, this is one PE patient I would actually like to see an ABG on. If she has evidence of a severe a-a gradient then there might actually be something to this, but with normal vitals & pulse-ox the likelihood of this is pretty low.

 

[streetdoc]

So in a patient with metastatic cancer and known PEs you were cool sending her out subtherapeutic? Maybe after a good discussion of the risks and benefits of adding temporary LMWH. But an INR of 1.5 is nearly normal and I tend not to like normal INRs in people with PEs and cancer.

Duplex ultrasounds are also great for diagnosing DVTs, but I'm not sure there is great evidence that no DVT means no PE. After all the DVT, or at least part of it, had to leave the leg to get to the lung.

That is exactly my line of thinking. The US would help me stratify just how aggressive I needed to be (send home vs. set up bridging vs. maybe even admission). Every pt that is subtherapeutic does NOT need admission or even lovenox. That would just be rediculous (and expensive). So, I was thinking if she has NO huge obvious DVT, then carry on with her doctor's coumadin changes as planned. However, if there is a massive clot then lets be a bit more aggressive and go that extra mile of setting up bridging, out pt rechecks, etc. I was trying to tally the cost in my head of US in the ER vs just going ahead and setting all that stuff up which is a pain after hours. I thought it would be a wash and with the US I atleast address the pts concern AND I am not on the phone for 20 minutes.

I don't know. That was my thought last night. Does that seem reasonable?

 

[xaelia]

Does that seem reasonable?

Ordering a sham ultrasound costing several hundred dollars in place of a rational discussion with the family and/or primary care physician?

Give them a SQ dose of LMWH or alternative de rigueur and have them follow-up the next day-ish for an INR check and repeat SQ dose of anticoagulant as needed.

 

[jbar]

I don't understand why when there is bilateral leg edema so many people are trying to rule out DVT. I had a patient who was sent to the ED for the same thing. The chance of a bilateral DVT is pretty low, so if you think the edema is due to a clot anatomically it would have to be IVC above the level of the bifurcation. (Clearly there are other causes of edema, low albumin, CHF etc) So my question is if you are really thinking she has a clot somewhere, do you need a study to look at her IVC?

 

[Arcan57]

I don't understand why when there is bilateral leg edema so many people are trying to rule out DVT. I had a patient who was sent to the ED for the same thing. The chance of a bilateral DVT is pretty low, so if you think the edema is due to a clot anatomically it would have to be IVC above the level of the bifurcation. (Clearly there are other causes of edema, low albumin, CHF etc) So my question is if you are really thinking she has a clot somewhere, do you need a study to look at her IVC?

Filters are thrombogenic and will increase your risk of clotting at the filter.

 

[Rendar5]

I don't understand why when there is bilateral leg edema so many people are trying to rule out DVT. I had a patient who was sent to the ED for the same thing. The chance of a bilateral DVT is pretty low, so if you think the edema is due to a clot anatomically it would have to be IVC above the level of the bifurcation. (Clearly there are other causes of edema, low albumin, CHF etc) So my question is if you are really thinking she has a clot somewhere, do you need a study to look at her IVC?

Depending on the patient circumstance, you may be correct and a CT angio may be the more appropriate study to evaluate clot burden. But in this case that may be a bit overkill and is a higher risk study to do than an u/s (potential nephrotoxicity of contrast dye).

 

[crewmaster1]

I don't understand why when there is bilateral leg edema so many people are trying to rule out DVT. I had a patient who was sent to the ED for the same thing. The chance of a bilateral DVT is pretty low, so if you think the edema is due to a clot anatomically it would have to be IVC above the level of the bifurcation. (Clearly there are other causes of edema, low albumin, CHF etc) So my question is if you are really thinking she has a clot somewhere, do you need a study to look at her IVC?

I totally agree with this. I was simply answering the question of u/s or not. Why anyone would get a D-dimer on a patient with cancer and h/o of PE to r/o a DVT is beyond me. The pre-test probability is just too high for that test satisfy me alone, and you know it will be elevated anyways. I agree that with bilateral leg edema, a DVT in the leg isn't the first, second, or probably even fifth thing that jumps to my mind.

 

[streetdoc]

In this case I just hate having to deal with a test i did not order. we get this a lot with our urgent care providers. This is the second elevated ddimer pt I have gotten from them that was sent for a chest CT that has a contrast allergy. who gets a ddimer in this type of pt anyway?! But then we in the ED are left to have long discussions with pts about complex issues over a test that never should have been ordered. The pts come with an expectation and i have to try and satisfy them to keep my PG scores up and my pt complaints down. I guess I didn't do enough for them as I see she came back 24 hrs later and was admitted for no clear reason with normal gas, normal labs, normal imaging. wtf?

So several mentioned covering her with LMWH. are you guys covering every suntherapeutic INR you find in the ER, because this is not my current practice (i just tell them their INR and they need to f/u). Or how is the decision made to cover because I'm not aware of anything on this. That's why I was thinking if I saw clot on US, then I'd cover, otherwise just follow up.

streetdoc

 

[deleted109597]

Just because they're sent to you doesn't mean you need to do their work. If they really want a study, there are outpatient sites that can perform those.
Comically, we get someone every day from the outpatient centers with dx of DVT. I really wish they could just go back to their PMD to get lovenox teaching/coumadin.

If they don't have concern for some massive clinical finding, the fact that they are subtherapeutic doesn't terribly concern me. Now, if they were at 1, it might make me consider giving them a longer course of lovenox, but otherwise no big deal. 1.5 is the same as 3.5 as far as I'm concerned.

As an aside, I prefer ordering US in pregnant patients with chest pain/SOB, as the treatment is the same if they have DVT or PE. If I can save their fetus and breast tissue the radiation, I will. If the US is negative, then I have to consider imaging their chest. Completely different patient than this one.

 

[deleted109597]

doublepost error......

 

[EMRAGE]

When all is said an done:

No US or CT 4 PE. Would draw PT/INR.

1. Normal Vitals: Call PCP and Home with continued Coumadin therapy. Follow-up next day. Treat pain if present.

2. Normal Vitals but concerned family: Admit. Anticoagulation with Heparin or Lovenox. Continue w/ Coumadin.

3. Abnormal Vital and Concerning symptoms: Back to #2

4. Code: ? DNR status

The rest is b/w her and GOD. Treat pain and make comfortable. Explain thought process to family. Never would I draw a D-dimer or do radiography on this pt.

RAGE

 

[youngdoc8205]

I've run into this a few times both in IR and surgery:

you don't need to get an US in a patient with with an IVC filter, and a "swole" leg, unless you want to 1)diagnose other things i.e. cellulitis/lymphedema, and need to r.o acute DVT, because as someone already said, IVC filters are thrombogenic and she likely has old clots

2)B/l LE edema in a patient with an IVC filter who is hypercoagulable could mean IVC thrombosis, which will need to be diagnosed and treatedwith clot retrieval/thrombolysis, unless she is hospice (if she was I assume you wouldn't be asking this question)

also, out of curiosity, do you happen to know how this lady came to have an IVC filter and be on anti-coagulants? that is the general recommendation of the PIOPED study, because both work better together than they do separately, but seldom is that followed here

if she is on anti-coagulants, than LMWH is actually better for anti-coagulation in pts with neoplastic disease for clot prevention than the other drugs out there, so she should be on that anyway

 

[Venko]

I came across this situation last night and was hoping for some outside input as to if the pt needs an US/DVT rule out or not.

Pt is 65ish F with history of metastatic cancer and PEs. Has an IVC filter in place. On coumadin but last INR (the day before) was 1.5 and she has not adjusted her dosing yet. She had a work up at local urgent care where a ddimer was obtained (I'm really not sure why) and it was elevated. they sent her to the ER for a CT chest. that simply was not going to happen not to mention she has a contrast allergy which is anaphylaxis. Anyway, the family was quite concerned she had another clot. Now, with the subtherapeutic INR and her history it certainly is possible, however she already has a filter.

So, would you US her legs to look for clot? Is that really going to change management?
Thanks for input, I'm just rehashing a busy night and trying to make sure I am doing the right thing.

streetdoc

For me, I am going to want to get this patient therapeutic again no matte what. If this patient was dyspneic or had mild hypotension or something I would get an echo. If the patient was very sick and I am wondering if I should give thrombolytics then I would get the lower extremity dopplers.

If the patient as you describe is quite stable, sent to ED for a CT because of an elevated D-Dimer, and is subtherapeutic I would probably arrange for lovenox for bridging and increase the coumadin and give close follow up.

There was question raised above about a saddle embolus, but even with a saddle embolus if there is no hemodynamic consequence she would not be a thrombolytic candidate and would again be made therapeutic on coumadin. The resorption of such clot will take months and she would not be kept in the hospital for that experience.

The only remaining clinical decisions for this patient are:
Is there right heart strain that would imply inpatient monitoring is needed?
Is the patient so moribund that I should be considering thrombolytic therapy, surgical embolectomy, and or ECMO?

Outside of these two questions, she needs to become therapeutic and have close follow up....

2)B/l LE edema in a patient with an IVC filter who is hypercoagulable could mean IVC thrombosis, which will need to be diagnosed and treatedwith clot retrieval/thrombolysis, unless she is hospice (if she was I assume you wouldn't be asking this question)

Interestingly, of the four patients I have seen with complete IVC thrombus all have looked terribly ill initially and none have needed clot retrieval or thrombolysis. The first time vascular and IR attending suggested to me that there is nothing but support to do for these patients I was mortified, but you know what they were right. There description to me was that the patients will develop, "collateral," flow....it sounded crazy to me, but they have been right four times so far.

When all is said an done:

No US or CT 4 PE. Would draw PT/INR.

1. Normal Vitals: Call PCP and Home with continued Coumadin therapy. Follow-up next day. Treat pain if present.

2. Normal Vitals but concerned family: Admit. Anticoagulation with Heparin or Lovenox. Continue w/ Coumadin.

3. Abnormal Vital and Concerning symptoms: Back to #2

4. Code: ? DNR status

The rest is b/w her and GOD. Treat pain and make comfortable. Explain thought process to family. Never would I draw a D-dimer or do radiography on this pt.

RAGE

Wow this may be a bit oversimplified...there are other interventions that ED docs should be aware of for patients with thrombophillic diseases other than heparin, coumadin, lovenox, and God 🙂

Don't forget for the really sick patients, thrombectomy, thrombolytics, and ECMO.

This is the second elevated ddimer pt I have gotten from them that was sent for a chest CT that has a contrast allergy. who gets a ddimer in this type of pt anyway?!

streetdoc

If a patient is low risk by Wells, D-Dimer is an appropriate next step. If positive and they have a contrast allergy than consider V/Q scan. It is a nuclear medicine test and does not use an iodinated contrast.

The VQ scan would be all but dead if it not for those with CKD and contrast allergies. The D-Dimer is not an unuseful test just because a patient has a contrast allergy...

TL

 

[Venko]

.

 

[Venko]

.

 

[Venko]

.

 

[xaelia]

Now, if they were at 1, it might make me consider giving them a longer course of lovenox, but otherwise no big deal. 1.5 is the same as 3.5 as far as I'm concerned.

The patient described is someone I might treat more like someone with a mechanical valve, considering her high risk for thrombogenesis and prior morbidity associated with said thrombogenesis. The cost to a single dose of enoxaparin/fondaparinux/etc. is dwarfed by the benefits, particularly in the context of someone sent to the ER by another physician - a time where bad outcomes never look good front of an attorney.

Now, if she were symptomatic/abnormal vital signs/asymmetric leg edema, any number of the otherwise discussed further steps in conservative management/evaluation might be appropriate.

 

[gutonc]

The D-Dimer is not an unuseful test just because a patient has a contrast allergy...

TL

No, but it is completely useless in somebody with known malignancy (as the OP's patient was).

The right thing (IMHO) for the UC to do in this case (assuming no pulm sxs) was treat with lovenox and send her back to her oncologist (not PCP) in the morning for a lifelong rx of lovenox since it has better outcomes in malignancy.

The OP just got hosed on this one.

 

[Venko]

No, but it is completely useless in somebody with known malignancy (as the OP's patient was).

The right thing (IMHO) for the UC to do in this case (assuming no pulm sxs) was treat with lovenox and send her back to her oncologist (not PCP) in the morning for a lifelong rx of lovenox since it has better outcomes in malignancy.

The OP just got hosed on this one.

Entirely agree.

 

[gan911]

lovenox, send home to f/u with whoever for coumadin. The end result would still be anticoagulation regardless if it is a DVT or PE?
She's already got the rest of the preventive stuff including an IVC filter. What else is left? if she's symptomatically dyspneic or hypoxic, it might be a different story.

 

[youngdoc8205]

sorry Thymeless, you are absolutely correct, in most cases you do not have to do anything

where intervention is required in particular is in iatrogenic causes of IVC thrombosis: long term venous access, HD access, or history of IVC surgery (emedicine article)

a thrombectomy is indicated in the case of phlegmasia

if the clot extends to the beyond to the level of the renal arteries and above (where it can cause a bevyy (?sp) of problems) (article in vascular/endovascular surgery article, can't remeber exact citation, done at INOVA fairfax though)

of course the above are relatively rare, as is IVC thrombosis in general, though with the increased utilization of IVC filters I feel like we will be seeing much more of these (ain't technology great)

 

[TysonCook]

LVX, f/u w/ pcp. If unilateral, symptomatic etc, further eval.

 

[baj6974]

I came across this situation last night and was hoping for some outside input as to if the pt needs an US/DVT rule out or not.

Pt is 65ish F with history of metastatic cancer and PEs. Has an IVC filter in place. On coumadin but last INR (the day before) was 1.5 and she has not adjusted her dosing yet. She had a work up at local urgent care where a ddimer was obtained (I'm really not sure why) and it was elevated. they sent her to the ER for a CT chest. that simply was not going to happen not to mention she has a contrast allergy which is anaphylaxis. Anyway, the family was quite concerned she had another clot. Now, with the subtherapeutic INR and her history it certainly is possible, however she already has a filter.

So, would you US her legs to look for clot? Is that really going to change management?
Thanks for input, I'm just rehashing a busy night and trying to make sure I am doing the right thing.

streetdoc

Yes, the US is a great place to live, of course USA.

 

[gutonc]

Yes, the US is a great place to live, of course USA.

Qua?

 

[smq123]

Again, the coumadin needs to become therapeutic. If she continues to develop clots despite a therapeutic INR, then she will probably need to be switched to Pradaxa (shudder), Argatroban, Arixtra, or Lovenox.

This is off-topic, but why would the patient be switched to Pradaxa? The only indication so far for Pradaxa is A-fib. I don't think I could even get Pradaxa covered by insurance for a patient with a DVT/PE.

 

[BADMD]

PCCs.

"Hemodialysis".

:\

There is a suggesting in two (crappy) abstracts that Factor 7 works relatively well (ie, improved bleeding time). Of course they used a larger dose in the animal model than we would in humans. PCC worked about the same, but is available at fewer hospitals.

Charcoal hemoperfusion will probably work more rapidly than hemodialysis and remove more drug, assuming you can find a nephrologist who knows where they left the charcoal cartridge and can remember how to attach it.

I have to wonder about injecting thrombin. I know you aren't supposed to inject it, however that was due to formation of clots. While I'm not sure you would just inject a bunch IV, I would have to wonder if catheter directed IA thrombin might viable.

 

[Tiger26]

There is a suggesting in two (crappy) abstracts that Factor 7 works relatively well (ie, improved bleeding time). Of course they used a larger dose in the animal model than we would in humans. PCC worked about the same, but is available at fewer hospitals.

Charcoal hemoperfusion will probably work more rapidly than hemodialysis and remove more drug, assuming you can find a nephrologist who knows where they left the charcoal cartridge and can remember how to attach it.

I have to wonder about injecting thrombin. I know you aren't supposed to inject it, however that was due to formation of clots. While I'm not sure you would just inject a bunch IV, I would have to wonder if catheter directed IA thrombin might viable.

On a side note, we just got PCC and I brought down a GI-bleeder's INR from 12ish to 1.7 in about 2 hrs (though it might have been much less than that, 2 hrs just happened to be the time of the repeat INR)

 

[BADMD]

On a side note, we just got PCC and I brought down a GI-bleeder's INR from 12ish to 1.7 in about 2 hrs (though it might have been much less than that, 2 hrs just happened to be the time of the repeat INR)

Warfarin or dabigatran? I'm sure that PCC works for warfarin. Part of the problem with dabigatran is that the standard coagulation measures don't necessarily mean anything.

 

[Venko]

On a side note, we just got PCC and I brought down a GI-bleeder's INR from 12ish to 1.7 in about 2 hrs (though it might have been much less than that, 2 hrs just happened to be the time of the repeat INR)

Sweet stuff dude!

 

[Tiger26]

Warfarin or dabigatran? I'm sure that PCC works for warfarin. Part of the problem with dabigatran is that the standard coagulation measures don't necessarily mean anything.

Warfarin--it was pretty incredible--stayed down with no further dosing for at least the next 24 hrs while he was still in the unit with us

 

[streetdoc]

LVX, f/u w/ pcp. If unilateral, symptomatic etc, further eval.

So what criteria are you guys using to decide if you cover with lovenox? I just had a guy with hx of multi trauma/dvt months ago, got an IVC filter and is on coumadin. on his work up (for abdominal pain) his INR was low- 1.6 i think. This topic crossed my mind again. It is kind of a pain to get lovenox at my place (requires MD to call pharmacy, pharmacy to do their thing, pharmacy then calls nurse, etc) so I am not in the habit of doing it routinely. Should I be? and are their any guidelines you guys are using because i don't find anything on a quick search.
thanks,
streetdoc