D-Dimers D-Dimers | allnurses

D-Dimers

  1. 0 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.
  2. 24 Comments

  3. Visit  prep8611 profile page
    2
    From my experience d-dimers rarely mean anything anymore. My hospital barely does them, if we suspect PE the patient gets scanned. Sounds like ur docs need to implement better dvt prophylaxis
    Ir15hd4nc3r_RN and anotherone like this.
  4. Visit  maloneys profile page
    0
    Really, prep8611? I didn't know d-dimers weren't' used anymore!

    Both patients had pneumatic boots on.
  5. Visit  turnforthenurse profile page
    2
    D-dimers are used. Any time a D-dimer is elevated a patient gets a trip to CT w/ contrast and then they get a doppler of the lower extremities to look for DVT.
    applewhitern and One1 like this.
  6. Visit  juan de la cruz profile page
    9
    Using D-dimer as an adjunct in differential diagnosis of a patient presenting with a possible PE is not a crazy thought in the absence of other conditions that could also cause an elevated result such as recent surgery, trauma, liver disease. The test is part of the algorithm for PE. In your patient's case, the D dimer will be elevated because of the recent surgery and will have limited utility.

    The definitive test is a contrast CT of the chest but there are patients who have contraindications to IV dye or who are at risk for contrast nephropathy. Those patients tend to not get scanned so other findings such as elevated D-dimer, lower extremity VTE, and clinical suspicion of PE based on presentation justifies treatment with anticoagulation.

    Pneumatic boots can prevent lower extremity VTE but not always. Adding Heparin SQ or Enoxaparin SQ can decrease the likelihood. Ultrasound does not diagnose a PE.
    RNinLDRP620, applewhitern, One1, and 6 others like this.
  7. Visit  juan de la cruz profile page
    4
    ...and there are case reports of patients who was found to have a PE yet never evidence of a lower extremity VTE. The thought is that the clot may have embolized from an upper extremity source or a "de novo" PE (meaning it originated in the lung itself).
  8. Visit  BostonFNP profile page
    1
    D-dimers still have some use, especially in ambulatory settings. I use serial elisa d-dimers in low-risk patients to rule out a DVT while keeping them away from the hospital. I will also use them in younger patients to avoid having to spiral CT them if I am not overtly concerned by their presentation.
    maloneys likes this.
  9. Visit  hodgieRN profile page
    2
    That's bs what the doc said. You don't need a level of 10,000 or above. Pts can have a PE with half that. A negative d-dimer is the only thing that matters. It's either is negative or inconclusive. True, there are dozens of other things that can raise the d-dimer, but if they need a scan, then they need a scan. But, if you can get a d-dimer and it is negative, then the pt can be spared the radiation. We order too many test these days. VQ scans are great. Nurses just don't like sitting in Nuc Med and would rather do a quick CT so they can get back to the unit. Not the best advocating.
    turnforthenurse and maloneys like this.
  10. Visit  maloneys profile page
    0
    Hmm, thanks for all the wonderful feedback. So in these cases, both patients should have been scanned then!

    How many days post-op would I expect to see an elevated D-dimer in the absence of liver diseases?
    Last edit by maloneys on Mar 11, '13
  11. Visit  edmia profile page
    3
    Quote from maloneys
    Hmm, thanks for all the wonderful feedback. So in these cases, both patients should have been scanned then!
    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
    murphyle, samadams8, and maloneys like this.
  12. Visit  blackvans1234 profile page
    0
    I just asked one of our nurses about this (I work in inpatient rehab)

    The d-dimer is indicated for pt's with s/s of dvt or pe. I guess the hospital has ranges of normal inflammation, and abnormal inflammation.
  13. Visit  coco317 profile page
    1
    When we have a positive d dimer there's a message that auto populates stating clinical correlation recommended.
    maloneys likes this.
  14. Visit  juan de la cruz profile page
    5
    Quote from maloneys
    How many days post-op would I expect to see an elevated D-dimer in the absence of liver diseases?
    There have been various studies that have addressed this. Most of the studies have shown that d dimer is elevated for at least a month post-op with the duration of elevation varying depending on the type of surgery done.

    A study done in General Surgery (intra-abdominal and retroperitoneal/liver) showed that d dimer is elevated for 25 days in intra-abdominal surgery and 38 days after retroperitoneal and liver surgery. See: Kinetics of D-dimer after general ... [Blood Coagul Fibrinolysis. 2009] - PubMed - NCBI

    In Orthopedic Surgery, d dimers were found to be elevated for 30 days after Total Knee Replacement. See: Course of D-dimer concentrations after total knee replacement surgery: effect of allogeneic and unwashed drainage blood transfusion - MU[]OZ - 2006 - Transfusion Alternatives in Transfusion Medicine - Wiley Online Library.

    Since this is an ICU forum, realize that in our patient population, there is limited utility of d dimers because our patients have other conditions that cause an elevated d dimer, thus, the predictive value of this test in ruling out a clot is not extensively used by critical care providers.
    murphyle, CrufflerJJ, Esme12, and 2 others like this.

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