Intra Pulmonary Thrombolysis

Prabakaran. C and Cath Team

Senior staff nurse, Cath lab department, Kauvery hospital, Tirunelveli

Introduction

Pulmonary thromboembolism refers to the condition in which thrombosis occurs in situ in pulmonary artery or multiple thrombi migrate from the systemic circulation to the pulmonary vasculature. Most of the bloods clots arise from the deep veins of the lower extremity and pelvis

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 and delirium (in elderly patients).

Background

A 23 years old female with the gestational history of P1L1 underwent LSCS at an outside hospital, On POD 2 referred with complaints of sudden onset of syncopal attack, and followed by breathlessness, Echo done outside showed acute cor pulmonale/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

Hemoglobin	9.0 g/dl
Urea	13.75mg/dl
Creatinine	0.62mg/dl
Random 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 shows exaggerated contraction, acute corpulmonale due to probable embolism.

Doppler Study of Both Lower Limb Venous System

No Saphenofemoral & Saphenopopliteal junction’s incompetency.

No evidence of perforator incompetence.

No evidence of acute deep venous thrombosis.

CT Scan Pulmonary Angiogram

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

Ultrasound Scan of Abdomen & Pelvis

Postpartal bulky uterus.

Gall bladder wall edema.

Normal study of solid abdominal organs.

Ultrasound Scan of abdomen & pelvis

Post-partum status of uterus

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 was found 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 gm 1-0-1)
IV PPIs (Inj. Pantocid 40 mg 1-0-1)
Analgesics (Inj. Para 1gm IV sos) and other supportive drugs.

Medications

Drugs	Dose
Inj. Lmwh	40 mg
Tab. Secrox	500 mg
Tab. Rbp	20 mg
Tab. Acitrom	2 mg
Tab. Elixaban	2.5 mg
Tab. Emanzen forte
Tab. Livogen – z
Tab. Shelcal – xt
Syr. Citralka

Nursing Intervention

Prevent venous stasis: Encourage ambulation and active and passive leg exercises to prevent venous stasis.
Monitor thrombolytic therapy: Monitoring thrombolytic and anticoagulant therapy through INR or PTT.
Manage pain: Turn patient frequently and reposition to improve ventilation-perfusion ratio.
Manage oxygen therapy: Assess for signs of hypoxemiaand monitor the pulse oximetry
Relieve anxiety: Encourage the patient to talk about any fears or concerns related to this frightening episode.
Urine output and abdomen girth monitored hourly.
Patient was advised to take clear liquids followed by semi solid diet.
A nurse can help reduce the risk of thrombosis through various strategies, such as educating people on the importance of leg exercises, encouraging movement throughout the day, using intermittent pneumatic compression devices to promote blood flow, monitoring and changing catheter or intravenous (IV) placement to prevent blood clot formation, 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 advice.

Post ECHO

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

Mr. Prabakaran. C
Senior staff nurse, Cath lab department

Intra Pulmonary Thrombolysis

Intra Pulmonary Thrombolysis

Prabakaran. C and Cath Team

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