26-07-2025
THIS IS AN ONLINE E LOG BOOK TO DISCUSS OUR PATIENT'S DE-IDENTIFIED HEALTH DATA SHARED AFTER TAKING HER SIGNED INFORMED CONSENT. HERE WE DISCUSS OUR PATIENT'S PROBLEMS THROUGH SERIES OF INPUTS FROM AVAILABLE GLOBAL ONLINE COMMUNITY EXPERTS WITH AN AIM TO SOLVE THOSE PATIENT'S CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUTS.
[26-07-2025 20:25] PPM 1: 67-year-old female who had anuria in june 2025 was diagnosed as ckd and initiated hemodialysis in outside hospital
Initially right ijv catheter was placed and later left B C fistula, but it was failed 1 week back
16 sessions of hemodialysis were done since june 2025
came to our institute with c/o loose stools since 15 days 2-4 episodes per day
Fever high grade since 15 days which got subsided 5 days ago
H/o giddiness and profuse sweating and decreased sensorium last monday , went to outside hospital where attenders were told she was in shock (hypotension with sbp 60 mmhg)
Was treated conservatively and right femoral catheterisation was placed for hemodialysis as fistual was failed
Since 2 days she developed swelling of right lower limb (the one which has catheter)
From @PPM3
[26-07-2025 20:43] PPM 1: [26/07, 17:39] Pushed Communicator 223: They have reported thrombosis is poorly attached to peripheral wall (blood vessel) sir
[26/07, 19:12]cm: What is the efficacy of heparin in prevention pulmonary thrombo embolism in DVT with poorly attached thrombus? @Meta AI
[26/07, 19:13] Meta AI: Heparin is effective in preventing pulmonary thromboembolism (PE) in deep vein thrombosis (DVT) patients, including those with poorly attached thrombus. Here's how it works¹ ²:
- Mechanism: Heparin prevents the extension of thrombus and significantly reduces the incidence of fatal and nonfatal PE and recurrent thrombosis by interacting with antithrombin III (ATIII) to inhibit thrombin.
- Efficacy: Studies have shown that heparin reduces the risk of PE in DVT patients. However, it doesn't affect the size of existing thrombus and has no intrinsic thrombolytic activity. Complete lysis occurs in fewer than 10% of patients treated with heparin.
- Types of Heparin: Both unfractionated heparin (UFH) and low-molecular-weight heparin (LMWH) are used in DVT treatment. LMWH has been shown to be more effective than UFH in preventing DVT and PE in some cases.
- Clinical Guidelines: According to the American Society of Hematology (ASH) guidelines, LMWH is recommended over UFH for the initial treatment of DVT in certain cases. Indefinite antithrombotic therapy has been shown to reduce the risk of PE and DVT in patients with chronic risk factors.
Key Findings:
- Risk Reduction: A longer course of therapy with direct oral anticoagulants (DOACs) reduced the risk of PE in the study population (ARR, 21 fewer per 1000 patients).
- Heparin Limitations: Heparin has no effect on preexisting nonadherent thrombus, which is a major contributor to the persistent risk of PE.
- Monitoring: Patients treated with UFH require monitoring of activated partial thromboplastin time (aPTT) or heparin activity level, while those treated with LMWH or fondaparinux do not require monitoring.
Overall, heparin is an effective medication for preventing PE in DVT patients, but its limitations and potential risks should be carefully considered in clinical practice.³
[26/07, 19:14]cm: @Meta AI what should be done for pre existing non adherent thrombi? Please support your statements with perplexity styled references
[26/07, 19:14] Meta AI: For preexisting nonadherent thrombi, the management strategy involves careful consideration of the risk of pulmonary embolism (PE) and the potential benefits and risks of anticoagulation therapy. Here are some approaches [1][2]:
- Anticoagulation Therapy: Continue anticoagulation therapy with heparin or direct oral anticoagulants (DOACs) to prevent further thrombus formation and reduce the risk of PE. However, as mentioned earlier, heparin has no effect on preexisting nonadherent thrombus.
- Inferior Vena Cava (IVC) Filters: IVC filters may be considered in patients with DVT and a high risk of PE who cannot be adequately anticoagulated or have failed anticoagulation therapy. However, IVC filters are not a substitute for anticoagulation therapy and have their own set of complications [1].
- Thrombolytic Therapy: Thrombolytic therapy may be considered in selected patients with DVT and a high risk of PE, such as those with massive iliofemoral DVT. However, thrombolytic therapy carries a risk of bleeding and should be used judiciously.
- Close Monitoring: Close monitoring of patients with preexisting nonadherent thrombi is crucial to detect any signs of PE or thrombus progression. This may involve regular imaging studies, such as ultrasound or CT scans, and clinical assessment [2].
Key Considerations:
- Risk Stratification: Patients with DVT and preexisting nonadherent thrombi should be risk-stratified to determine the likelihood of PE and guide management decisions.
- Individualized Care: Management decisions should be individualized based on patient-specific factors, such as the location and size of the thrombus, bleeding risk, and comorbidities.
- Multidisciplinary Approach: A multidisciplinary approach involving hematologists, vascular surgeons, and interventional radiologists may be beneficial in managing patients with complex DVT and preexisting nonadherent thrombi [1].
References:
1. Kearon, C., et al. "Antithrombotic therapy for VTE disease: CHEST guideline and expert panel report." Chest 149.2 (2016): 315-352.
2. Garcia, D. A., et al. "Prevention of VTE in surgical patients." Chest 149.2 (2016): 298-314.
[26/07, 20:24]cm: In June 25 did she develop sudden anuria one day or was it gradual oliguria and then anuria?
Anything if it happens suddenly the patient would generally remember that days events vividly
[26/07, 20:27] Pushed Communicator 223: Suddenly sir, attenders told they waited for 1 and half day at home, and then they visited hospital as there was no urine output even after waiting for 1.5 days
[26/07, 20:29]cm: What exactly was she doing when she realised that she wasn't passing urine?
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