A 64-year-old woman is hospitalized after injuring her right hip when she slipped on ice while carrying groceries. X-ray reveals a right femoral neck fracture, and the patient undergoes a total hip arthroplasty with no operative complications. Two days after surgery, the patient develops acute hemodynamic decompensation. A contrast-enhanced CT scan of the chest is immediately obtained; a sagittal view is shown below. In-hospital administration of which of the following is most appropriate for reducing the risk of patients developing this complication?

Question

A 64-year-old woman is hospitalized after injuring her right hip when she slipped on ice while carrying groceries.  X-ray reveals a right femoral neck fracture, and the patient undergoes a total hip arthroplasty with no operative complications.  Two days after surgery, the patient develops acute hemodynamic decompensation.  A contrast-enhanced CT scan of the chest is immediately obtained; a sagittal view is shown below.  In-hospital administration of which of the following is most appropriate for reducing the risk of patients developing this complication?

Quizplus · Accepted Answer

11ec160b_3a1a_0e08_9249_71451a4e84c7_MD0001_00 This contrast-enhanced CT image reveals a large filling defect within the lumen of the pulmonary artery, which is consistent with pulmonary embolism (PE). The thromboembolus usually originates in the deep veins of the lower extremities and travels through the inferior vena cava and right side of the heart to reach the pulmonary circulation. Large emboli lodge in the pulmonary artery bifurcation ("saddle emboli") and may cause severe hypotension or sudden cardiac death, whereas smaller emboli occlude peripheral pulmonary arterial branches. In most cases, pulmonary emboli are multiple, with the lower lobes involved more often than the upper lobes. Many hospitalized patients are at increased risk for venous thromboembolism (VTE) (ie, PE or deep vein thrombosis) due to trauma, prolonged immobilization, or underlying conditions that contribute to a hypercoagulable state (eg, cancer, infection, pregnancy). Patients undergoing large orthopedic surgeries (eg, hip replacement) are at particularly high risk of VTE. Although the risk of VTE in hospitalized patients cannot be completely eliminated, administration of prophylactic anticoagulation greatly reduces risk. Low-molecular-weight heparin (eg, enoxaparin) is preferred in most patients due to proven efficacy and relatively low risk of adverse effects. In patients at high risk of VTE, the slightly increased risk of bleeding is strongly outweighed by the reduced risk of VTE (and its associated mortality) provided by prophylactic anticoagulation. Early ambulation also helps reduce the risk of VTE. (Choice A) Beta-adrenergic antagonists (eg, metoprolol) may lower the risk of perioperative myocardial infarction or aortic dissection, but they do not reduce the risk of VTE. (Choice B) Fresh frozen plasma is used to reverse the effects of warfarin or to provide coagulation factors to patients experiencing massive hemorrhage. It does not reduce the risk of VTE and may even exacerbate an underlying hypercoagulable state. (Choice C) Intravenous hydration can help prevent perioperative dehydration and prerenal acute kidney injury. (Choice E) Perioperative antibiotics (eg, cefazolin) may help prevent surgical wound infections. (Choice F) Tissue plasminogen activator is indicated in the treatment of massive PE complicated by hemodynamic instability. However, it is not appropriate for VTE prophylaxis due to the relatively high risk of serious bleeding complications (eg, intracranial hemorrhage). Educational objective: The risk of venous thromboembolism (ie, pulmonary embolism or deep vein thrombosis) in hospitalized patients can be greatly reduced with the administration of prophylactic anticoagulation, usually with low-molecular-weight heparin.

A 64-Year-Old Woman Is Hospitalized After Injuring Her Right Hip