Postpartum Pulmonary Embolism

• Paula is a 36-year-old female who is 6 days post-cesarean delivery.
• Paula's current medication is a multivitamin.
• Paula was brought to the emergency department due to sudden shortness of breath, chest pain, and mild confusion.
• Paula is diaphoretic and appears anxious.
• Paula's blood pressure is 160/95 mmHg, heart rate is 110 bpm, and oxygen saturation is 88% on room air.
• Physical examination reveals tachypnea and mild cyanosis.
• ECG shows sinus tachycardia.
• D-dimer test is significantly elevated.
• CT pulmonary angiogram confirms a large pulmonary embolism in the right main pulmonary artery.
• Paula is diagnosed with a high-risk pulmonary embolism causing hemodynamic instability.

Treatment Plan

• Paula is placed on supplemental oxygen to maintain oxygen saturation above 90%.
• Large bore intravenous lines are established for fluid resuscitation and medication administration.
• A continuous intravenous heparin infusion is initiated to prevent further clot formation and promote clot resolution.
• Monitoring includes vital signs, oxygen saturation, and aPTT.

Heparin weight-based infusion (VTE/DVT/PE)

• Initial Bolus is 80 units/kg (MAX 10,000 units) and initial infusion rate is 18 units/kg/hr (MAX 2100 units/hr).
• With an Anti-Xa Level less than 0.1 units/mL, bolus 80 units/kg (MAX 10,000 units) and increase infusion rate by 4 units/kg/hr.
• With an Anti-Xa Level of 0.1-0.29 units/mL, bolus 40 units/kg (MAX 5000 units) and increase infusion rate by 2 units/kg/hr.
• With an Anti-Xa Level of 0.3-0.7 units/mL, make no change to bolus or infusion rate.
• With an Anti-Xa Level of 0.71-0.8 units/mL, make no change to bolus and decrease infusion rate by 1 unit/kg/hr.
• With an Anti-Xa Level of 0.81-0.99 units/mL, make no change to bolus and decrease infusion rate by 2 units/kg/hr.
• With an Anti-Xa Level of 1 unit/mL or greater, hold infusion for 1 hour and decrease infusion rate by 3 units/kg/hr.

aPTT

• For an initial dose, bolus 80 units/kg and begin infusion at 18 units/kg/hr.
• If aPTT is less than 35 seconds, bolus 80 units/kg and increase infusion rate by 4 units/kg/hr.
• If aPTT is 35-45 seconds, bolus 40 units/kg and increase infusion rate by 2 units/kg/hr.
• If aPTT is 45-60 seconds, make no bolus and increase infusion rate by 2 units/kg/hr.
• If aPTT is 60-80 seconds, make no change to bolus or infusion rate.
• If aPTT is 80-90 seconds, make no bolus and decrease infusion rate by 2 units/kg/hr.
• If aPTT is greater than 90 seconds, hold infusion for 1 hour then restart and decrease infusion rate by 3 units/kg/hr.

Multiple Choice Questions

• A patient taking warfarin should avoid NSAIDs for headache relief.
• When educating a patient on self-administering enoxaparin, include that the patient should pinch their skin and administer the injection subcutaneously.
• A concern for a patient taking dabigatran for atrial fibrillation is renal impairment.
• For a patient who received a double dose of heparin and is bleeding, the nurse can prepare IV protamine sulfate.
• Principles of warfarin therapy include monitoring lab results for a target INR of 2-3 and watching for excessive bruising or unusual bleeding.
• For a patient with DVT being treated with a heparin infusion, the nurse would monitor effectiveness by noting the activated partial thromboplastin time (aPTT).
• Clopidogrel works by inhibiting platelet aggregation to prevent clot formation.
• When explaining warfarin to a female patient, include that it is a vitamin K antagonist, does not cross the placenta, is used for long-term anticoagulation therapy, and is metabolized by the liver.
• Protamine sulfate is the antidote for heparin.
• Clopidogrel is indicated for the reduction of myocardial infarction and stroke.