D-Dimers - page 3

I wonder if someone might help shed some light here. Post-op day 4, abdo abcess drainage patient who went from room air to tachypneic 30-40 and 100% FiO2 over a couple of hours. I did a D-dimer as... Read More

  1. Visit  maloneys profile page
    0
    Thank you, Juan de la Cruz, for taking the time to answer my questions and for citing those sources. I'm afraid my continued learning is going down the tubes working in a small, peripheral hospital where there are no docs on at night. I appreciate your input!
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  3. Visit  prep8611 profile page
    2
    I would say by their presentation yes they absolutely should have been scanned. The NP and other nurse mentioning vq scan both made solid points. Pt is post op with shortness of breath and tachycardia..... Could be PE, atelectasis, pna, sepsis Remember that assessment is always used before lab readings and the scan is just allowing you to a picture of whats going on.
    WildflowerRN and maloneys like this.
  4. Visit  samadams8 profile page
    0
    Quote from edmia
    Yes!

    With an elevated ddimer all you have is an inconclusive or low specificity result (50% Sp for ddimer). This means the test is good to rule out embolic disease but not to rule it in.

    Sent from my iPhone using allnurses.com

    correct.
  5. Visit  maloneys profile page
    0
    I agree, prep8611, and I wasn't using the d-dimer to try to diagnose PE, but without a doc available, it is typical for us to do labs following the physical assessment. That way, if we do need to call the doc, he/she has all the stats.

    I wonder if, in an ICU setting, the d-dimer is at all necessary then, particularly following surgery or trauma or in the presence of liver disease?
  6. Visit  prep8611 profile page
    1
    That's what I was saying before, the d diner may be ordered but we rarely use it. D dimer will also be very elevated in CA patients who tend to have medical icu admissions.
    maloneys likes this.
  7. Visit  juan de la cruz profile page
    1
    Quote from maloneys
    I wonder if, in an ICU setting, the d-dimer is at all necessary then, particularly following surgery or trauma or in the presence of liver disease?
    Yes, it has very limited utility in our setting as ICU providers and nurses. There's a multitude of other reasons that can elevate D-dimer in ICU patients other than what you mentioned...MI, cancer, inflammatory conditions, and even infections can cause it to to be elevated.

    The test is used in out-patient settings and ED's in conjunction with physical presentation that is concerning for a VTE or PE in patients with no other reason to have an elevated D-dimer. If the D-dimer is normal, there won't be a need to scan. If it's elevated, you can either scan or proceed to treat based on a high suspicion for PE if scanning is not feasible.
    maloneys likes this.
  8. Visit  Esme12 profile page
    0
    Quote from maloneys
    I wonder if someone might help shed some light here. Post-op day 4, abdo abcess drainage patient who went from room air to tachypneic 30-40 and 100% FiO2 over a couple of hours. I did a D-dimer as I suspected a possible PE. Came back 6000. Doc said it would be elevated since the patient is 4 days post-op, and you need a result of 10 000 for it to indicate PE.

    Then a few days later, 3 day post-op cystectomy, same symptoms as patient above, D-dimer 3120, but ultrasound showed PE.

    I don't understand! Please help! Many thanks in advance.
    I am confused...how did an ultrasound see a Pulmonary emboli?
  9. Visit  juan de la cruz profile page
    2
    Quote from maloneys
    So in these cases, both patients should have been scanned then!
    Well, not necessarily. The contrast Chest CT Scan obviously gave you the diagnosis in both cases. However, what was the initial hesitation to get a CT Scan? Like I mentioned previously, there are patients that we worry about subjecting to IV dye (poor kidney function, dye allergy). In those cases, there are other things that can help with the diagnosis of PE.

    One, you can do a Dulpex Ultrasound of the legs and if a DVT is positive, then you will anticoagulate anyway. If there is high suspicion for a PE based on presentation, you can safely deduct that there is a source of a PE from the legs and a PE is likely.

    You can also do transthoracic echocardiogram or a 2-D Echo. PE is a clot in the pulmonary arterial circulation. You know that the RV pumps blood to the pulmonary arteries - if there is a significant PE, the RV will show strain on the 2-D Echo due to difficulty pumping blood through the pulmonary circulation. Evidence of R heart strain is a strong diagnostic indicator of a PE.

    Another test that was being done more commonly in the past is a V/Q Scan which only gives you PE probabilities and will not detect smaller PE's.
    Esme12 and maloneys like this.
  10. Visit  That Guy profile page
    1
    Quote from Esme12
    I am confused...how did an ultrasound see a Pulmonary emboli?
    I was also interested in this. Also a D-dimer only >10000 for PE? How does that work.
    Esme12 likes this.
  11. Visit  prep8611 profile page
    1
    Quote from juan de la cruz

    Well, not necessarily. The contrast Chest CT Scan obviously gave you the diagnosis in both cases. However, what was the initial hesitation to get a CT Scan? Like I mentioned previously, there are patients that we worry about subjecting to IV dye (poor kidney function, dye allergy). In those cases, there are other things that can help with the diagnosis of PE.

    One, you can do a Dulpex Ultrasound of the legs and if a DVT is positive, then you will anticoagulate anyway. If there is high suspicion for a PE based on presentation, you can safely deduct that there is a source of a PE from the legs and a PE is likely.

    You can also do transthoracic echocardiogram or a 2-D Echo. PE is a clot in the pulmonary arterial circulation. You know that the RV pumps blood to the pulmonary arteries - if there is a significant PE, the RV will show strain on the 2-D Echo due to difficulty pumping blood through the pulmonary circulation. Evidence of R heart strain is a strong diagnostic indicator of a PE.

    Another test that was being done more commonly in the past is a V/Q Scan which only gives you PE probabilities and will not detect smaller PE's.
    This guy is very intelligent. What he said ^
    maloneys likes this.
  12. Visit  maloneys profile page
    0
    Hesitation to do a scan was lack of docs to read the scan at night, due to absence of docs.

    Thank you very much for taking the time to do this teaching! I'm very appreciative.
  13. Visit  Rizz profile page
    1
    We do d dimers on our chest pain patients. It's standard protocol. Any d dimer out of normal range and the chest pain pt goes for a chest CT.

    I had a patient who was admitted with dehydration (not chest pain). Her dehydration had been resolved but I noted she had a respiratory rate of 29. Pt was also suddenly very fatigued and winded even getting up in bed when she had been walking the halls earlier in the day. I called the doc who ordered a d dimer. It came back at 2,000. Sent her for a chest CT and she had bilateral PE's. I've seen PE's in other nurse's patients with d dimers around 1,000 but in my own patients and in my friend's patient's I've not seen PE's with high d dimers below 1,000. In other words, I don't suspect a PE with a d dimer of 400. But >1,000 and I think it is possible-likely and >2,000 I expect a positive.

    I should mention this is in a med-surg unit. Not in ICU. (Didn't realize I was posting in an ICU forum)
    Last edit by Rizz on Mar 13, '13
    maloneys likes this.


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