Intra pulmonary thrombolysis

C. Prabakaran

Department of Cath lab, Kauvery hospital, Tirunelveli

Abstract

Pulmonary thromboembolism refers to the condition in which a single large thrombus or multiple thrombi migrate from the systemic circulation to the pulmonary vasculature.  Most of the blood clots arise from the “deep veins “of the lower and upper extremities. Patients with pulmonary thromboembolism may present with atypical symptoms, such as the following: seizures, syncope, abdominal pain, fever, productive cough, wheezing, decreasing level of consciousness, new onset of atrial fibrillation, haemoptysis, flank pain, delirium (in elderly patients).

Background

A 23 years old female, known case of P1L1/LSCS (POD-2) at outside hospital. She was referred with complaints of sudden onset of syncopal attack followed by breathlessness Echo done outside showed acute corpulmonle/acute pulmonary thromboembolism. Pre-procedural DVT Well’s score was 06/09.

On examination

Patient conscious, oriented, afebrile,

PR : 120/ min
BP :110/70 mmHg
CVS: S1 S2 (+)
RS : Bilateral air entry (+)
P/A : soft
CNS: NFND

Investigations

Haemoglobin: 9.0 g/dl

Urea: 13.75mg / dl

Creatinine: 0.62mg / dl

Randam Blood Sugar: 96mg / dl

Platelet Count: 244000 Cells / Cumm

Red Blood Cell: 3.70/cmm

INR: 1.15

Blood Grouping: A positive

Anti HCV Rapid: Nonreactive

HBs Ag: Nonreactive

HIV Rapid: Nonreactive

Bleeding and clotting time: 03 min/03 sec

Pre ECHO

RA, RV dilated, TR (mild), RV dysfunction, RV Apex showed exaggerated contraction, corpulmonale due to probable embolism.

Doppler study of both lower limb venous system

  1. No Saphenofemoral & Saphenopopliteal junctions incompetence
  2. No evidence of perforator incompetence
  3. No evidence of acute deep venous thrombosis

CT scan pulmonary angiogram

  1. Acute pulmonary thromboembolism involving both left & right pulmonary artery with extension into the segmental & sub segmental branches of upper & lower lobes.
  2. Right atrial & ventricular dilatation.
  3. Lung parenchyma normal. No evidence of any infarct.

Ultrasound Scan of abdomen & pelvis

  1. Post partal bulky uterus.
  2. Gall bladder wall edema.
  3. Normal study of solid abdominal organs.
  4. Bilateral minimal pleural effusion.

Intra pulmonary thrombolysis

Under local anesthesia and fluoroscopic guidance, the right femoral vein was punctured and pulmonary angiogram was done. Pulmonary angiogram showed thrombus in left pulmonary artery before branching.  Right pulmonary artery showed minimal thrombus in branching.

Intra pulmonary thrombolysis done with TNK 20 mg in left pulmonary artery.  Flow established in both pulmonary arteries with significant reduction in thrombus

Patient was treated with IV fluids,

  • IV antibiotics (Inj. CEFLEN 1.5 g 1-0-1)
  • IV PPIs (Inj. Pantocid 40 mg 1-0-1)
  • Analgesics (Inj. Para 1 g IV SOS) and other supportive drugs.

Medications

DrugDose
Inj. LMWH40 mg
Tab. SECROX500 mg
Tab. RBP20 mg
Tab. ACITROM2 mg
Tab. Elixaban2.5 mg
Tab. Emanzen Forte
Tab. Livogen. Z
Tab. Shelcal. XT
Syp. Citralka

Nursing intervention

  1. Prevent venous stasis: Encourage ambulationand active and passive leg exercises to prevent venous stasis.
  2. Monitor thrombolytic therapy: Monitoring thrombolytic and anticoagulant therapy through INR or PTT.
  3. Manage pain: Turn patient frequently and reposition to improve ventilation-perfusion ratio.
  4. Manage oxygen therapy: Assess for signs of hypoxemiaand monitor the pulse oximetry
  5. Relieve anxiety: Encourage the patient to talk about any fears or concerns related to this frightening episode.
  6. Urine output and abdomen girth monitored hourly.
  7. Patient was advised to take clear liquids followed by semi solid diet.
  8. A nurse can help reduce the risk of thrombosis through various strategies, such as:
  9. Educating people on the importance of leg exercises
  10. Encouraging movement throughout the day
  11. Using intermittent pneumatic compression devices to promote blood flow
  12. Monitoring and changing catheter or intravenous (IV) placement to prevent blood clot formation
  13. Regularly monitoring vital signs, such as heart rate and blood pressure

Individual education

A part of a nursing plan often includes providing education on a person’s condition. This may include information on topics such as lifestyle changes and strategies to reduce the risk of blood clots in the future information on what was performed while under their care (called an after visit summary) recommendations for future treatment, such as explaining referrals for additional therapy review of next steps, such as when to schedule follow-ups with primary care doctors

Outcome of the patient

On discharge patient DVT Well’s score was 01/09. General condition was good, vitals are stable, hence discharge the patient with follow up medical advices.

Post Echo

Case of pulmonary thromboembolism, RA, RV normal dimension, TR (mild). Pulmonary flow normalized, LV function and contraction was good.

Mr. C. Prabakaran
Senior staff nurse

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