Year : 2021 | Volume
| Issue : 4 | Page : 444-446
Pulmonary embolism in anticoagulated burn patient: A case report
Mohamed AlHarbi1, Amr AlKouny2, Ayaz Ahmed2, Borhan Hazazi2
1 Department of Anesthesiology, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
2 Department of Anaethesia, King Abdulaziz Medical City, Riyadh, Saudi Arabia
Department of Anaethesia, King Abdulaziz Medical City, P.O. Box: 22490, Riyadh - 11426
Source of Support: None, Conflict of Interest: None
|Date of Submission||21-Feb-2021|
|Date of Decision||28-Feb-2021|
|Date of Acceptance||02-Mar-2021|
|Date of Web Publication||02-Sep-2021|
Venous thromboembolism (VTE) represents a continuous threat to burn patients. While many thromboprophylaxis regimens exist, the best prevention protocol remains indefinable. We report a case of a burn patient who developed pulmonary embolism despite receiving VTE prophylaxis.
Keywords: Burn; cardiac arrest; pulmonary embolism; thromboembolic prophylaxis
|How to cite this article:|
AlHarbi M, AlKouny A, Ahmed A, Hazazi B. Pulmonary embolism in anticoagulated burn patient: A case report. Saudi J Anaesth 2021;15:444-6
| Introduction|| |
Burn patients have all the three components of Virchow's triad that may predispose to the development of venous thrombosis namely hypercoagulability, stasis, and endothelial injury. Hypercoagulability from increased fibrinogen, coagulation factors level and platelet count; stasis from prolonged immobilization and multiple surgical procedures; endothelial injury from the systemic inflammatory response and mechanical trauma from central venous catheters.
We report a case of a 54% total body surface area (TBSA) burn patient who developed pulmonary embolism two times despite receiving chemical and mechanical venous thromboembolism (VTE) prophylaxis.
| Case History|| |
A 43-year-old female patient (height 160 cm, weight 98 kg, BMI 38.3), transferred to the burn unit with 54% second- and third-degree flame burn in her upper limbs, lower limbs, and trunk before 2 weeks during which she was admitted in another hospital where she had burn escharotomy. She has a medical history of type 2 diabetes mellitus and her chest X-ray showed pneumonia, but she was maintaining good oxygen saturation on nasal cannula. Routine management for burn patients was started including deep venous thrombosis prophylaxis with subcutaneous unfractionated heparin.
Two days after admission the patient was taken to the operating room for debridement and skin grafting. During intubation she had an unexplained drop in oxygen saturation to less than 90% which improved gradually, and the patient was kept intubated and mechanically ventilated postoperatively. A computed chest tomography was done on the same day which showed acute right middle lobe segmental pulmonary embolism. Heparin infusion started and an inferior vena cava filter was placed. The patient was extubated after 10 days and maintained good oxygen saturation. A right sided peripherally inserted central catheter (PICC line) was done in the interventional radiology department 3 days after admission then removed and replaced in the left side due to right axillary vein thrombus and arm swelling. She underwent multiple excision and debridements with skin grafting under general anesthesia and heparin infusion was temporary suspended before each procedure. During bilateral lower limbs and back change of dressing under conscious sedation and almost after completion of the procedure the patient started to have respiratory distress and oxygen desaturation to less than 90% not responding to increasing the oxygen flow on the face mask, bag mask ventilation with 100% oxygen was started but the oxygen saturation did not improve, intubation was done and confirmed with carbon dioxide color conversion and chest auscultation. The airway pressure was high with sever bilateral wheezes which progressed to a silent chest inspite of giving salbutamol puffs through the endotracheal tube. She rapidly became bradycardic and hypotensive, intravenous atropine 1 mg and ephedrine 5 mg boluses were given but she deteriorated to pulseless electrical activity. Cardiopulmonary resuscitation was started and return of spontaneous circulation was successfully achieved after 2 cycles with one dose of epinephrine 1 mg given intravenously. Chest computed tomography was done which revealed new incidence of acute right upper, middle, and lower lobe segmental pulmonary embolism and enoxaparin was started. The patient stayed on mechanical ventilation and inotropic support for five days then she was extubated and maintained stable hemodynamics.
| Discussion|| |
The incidence of VTE in burn patients varies widely depending on many factors like age, obesity, wound infection, pneumonia, central venous access, TBSA percentage of burn, length of intensive care unit stay, and the number of surgical interventions.
Unfortunately there is no solid evidence from randomized controlled trials for VTE prophylaxis in burn patients, as a result there is no guidelines section specific for burn patient in the VTE guidelines, expect the American College of Chest Physicians Evidence-Based Clinical Practice Guidelines 8th Edition published in 2008, and this was removed from the further updates probably for the same reason. This could also be the reason for VTE management inconsistency between burn centers.
In a survey of the American burn association verified burn centers it was found that 23.9% of the centers do not routinely use either chemical or mechanical prophylaxis against VTE. Of those using VTE prophylaxis, 78% use chemical prophylaxis and 22% use mechanical prophylaxis.
A retrospective cohort study of 1111 burn patients comparing unfractionated heparin and enoxaparin given for the prevention of VTE, 5 patients (0.45%) experienced a symptomatic venous thromboembolic event and all five events occurred in the unfractionated heparin group.
Although there is a trend to use enoxaparin over unfractionated heparin for VTE prophylaxis in burn patients, standard dosing may be inadequate and dose adjustment achieved by measurement of anti-factor Xa levels or using certain dosing formulas that include patient weight and TBSA is recommended.
Intermittent pneumatic compression devices offer a considerable benefit whether combined with chemoprophylaxis in high-risk patients or when used alone if the patient clinical condition precludes chemoprophylaxis. The use of IVC filters in burn population is controversial as it was found to be associated with more resource utilization and higher mortality.
The diagnosis of PE can become difficult due to the non-specific signs and symptoms like dyspnea, tachypnea, hemodynamic instability, right ventricular dysfunction, and PE is known as “the great masquerader”. Bronchospasm and wheezes like the case presented can occur in PE as the initial presentation in some patients. The mechanism of bronchoconstriction in PE is not clear. It could be related to serotonin released from platelets of the clot. Another mechanism of bronchoconstriction could be due to reduction in PaCo2 in the affected areas of lung. Cardiac arrest in PE and in acute severe asthma will follow the standard advanced cardiopulmonary life support (ACLS) guidelines.,,
A big number of VTE in burn patients can be clinically occult and about 25% of burn fatalities had autopsy evidence of small pulmonary emboli, so an early decision to provide prophylaxis should be made when the patient is admitted with daily assessment considering changes in the patient's clinical condition implementing predictive models and risk scores.,
| Conclusion|| |
Burn patients have multiple risk factors for VTE. Early risk assessment, high index of suspicion and early start of appropriate VTE prophylaxis can result in a dramatic improvement in patient outcome.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Bagot CN, Arya R. Virchow and his triad: A question of attribution. Br J Haematol 2008;143:180-90.
King DR, Namias N, Andrews DM. Coagulation abnormalities following thermal injury. Blood Coagul Fibrinolysis 2010;21:666-9.
Pannucci CJ, Osborne NH, Wahl WL. Venous thromboembolism in thermally injured patients: Analysis of the National Burn Repository. J Burn Care Res 2011;32:6-12.
Kearon C, Akl EA, Ornelas J, Blaivas A, Jimenez D, Bounameaux H, et al
. Antithrombotic therapy for VTE disease: CHEST guideline and expert panel report. Chest 2016;149:315-52.
Ferguson RE, Critchfield A, Leclaire A, Ajkay N, Vasconez HC. Current practice of thromboprophylaxis in the burn population: A survey study of 84 US burn centers. Burns 2005;31:964-6.
Bushwitz J, LeClaire A, He J, Mozingo D. Clinically significant venous thromboembolic complications in burn patients receiving unfractionated heparin or enoxaparin as prophylaxis. J Burn Care Res 2011;32:578-82.
Lin H, Faraklas I, Cochran A, Saffle J. Enoxaparin and antifactor Xa levels in acute burn patients. J Burn Care Res 2011;32:1-5.
Pannucci CJ, Obi AT, Timmins BH, Cochran AL. Venous thromboembolism in patients with thermal injury: A review of risk assessment tools and current knowledge on the effectiveness and risks of mechanical and chemical prophylaxis. Clin Plast Surg 2017;44:573-81.
Baqui Z, Li W, Zakhary E, Buchanan P, Boakye EA, Jacobs D. Inferior vena cava filter utilization for burn patients in the United States: Analysis of the national burn repository. J Vasc Surg 2015;61:103S-4S.
Lavonas EJ, Drennan IR, Gabrielli A, Heffner AC, Hoyte CO, Orkin AM, et al
. Part 10: Special circumstances of resuscitation: 2015 American heart association guidelines update for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation 2015;132 (18 Suppl 2):S501-18.
Bansal DP, Maazuddin M, Viquasuddin M. Pulmonary embolism mimicking acute severe Asthma. J Assoc Physicians India 2018;66:11-2.
Jaff MR, McMurtry MS, Archer SL, Cushman M, Goldenberg N, Goldhaber SZ, et al
. Management of massive and submassive pulmonary embolism, iliofemoral deep vein thrombosis, and chronic thromboembolic pulmonary hypertension: A scientific statement from the American heart association. Circulation 2011;123:1788-830.
Caprini JA. Thrombosis risk assessment as a guide to quality patient care. Dis Mon 2005;51:70-8.