What is the cause of post-operative pain and hardening around the surgical site in a 76-year-old male following thrombectomy for Pulmonary Embolism (PE) removal?

From the Guidelines

The patient's post-operative pain and hardening around the incision site are likely expected outcomes following the thrombectomy procedure, and management should focus on pain control and monitoring for signs of infection or complications. The patient's presentation with pain when walking and hardening around the small 0.5 cm incision site in his left groin is consistent with normal healing tissue or possibly a small hematoma formation, which is not uncommon in patients on anticoagulation with Eliquis (apixaban) 1. The physical assessment reveals approximately 1 cm of hardening around the surgical site with some tenderness, but importantly, there are no signs of infection or bleeding. His laboratory values are largely unremarkable, with only slightly elevated glucose at 128 and chloride at 112.

Key Findings and Management

• The chest x-ray shows an ill-defined density in the right lung with volume loss, raising concern for possible right lower lobe pneumonia, and a follow-up CT chest would be appropriate to evaluate this finding 1.
• The patient's report of cough with mucus production since the procedure also warrants further evaluation for possible pneumonia.
• Management should include:
  • Resuming regular Tylenol (acetaminophen) 650-1000 mg every 6 hours as needed for pain.
  • Warm compresses to the incision site to help with discomfort.
  • Close monitoring of the surgical site for signs of infection or complications.
  • Advising the patient to return if he develops fever, increased pain, redness, swelling, or drainage from the incision site.

Considerations for Perioperative Pulmonary Complications

• The patient's advanced age is a risk factor for postoperative pulmonary complications, and close monitoring is necessary to prevent and manage these complications 1.
• The patient's history of pulmonary embolism and current anticoagulation therapy also increase his risk for pulmonary complications, and careful management of his anticoagulation and monitoring for signs of bleeding or thrombosis are necessary.

From the Research

Patient Assessment

• The patient is a 76-year-old male presenting with post-operative pain after a thrombectomy for pulmonary embolism (PE) removal.
• He has a surgical wound of about 0.5cm on the left groin and reports pain when walking, with hardening on the incision site.
• The patient denies fever, chills, shortness of breath, nausea, vomiting, and dizziness, but reports some cough with mucus since the procedure.
• Physical assessment reveals about 1cm of hardening around the surgical site, with some tenderness but no signs of infection or bleeding.

Laboratory Results

• CBC shows RBC 4.32, hemoglobin 13.1, hematocrit 39.4.
• CMP glucose 128, Chloride 112, otherwise unremarkable.
• The patient is currently on Eliquis.

Chest X-ray Results

• The chest X-ray reads "III-defined density right lung with volume loss in the right hemithorax. Right lower lobe pneumonia cannot be excluded. Correlate with CT chest."

Possible Pneumonia Treatment

• According to the study by 2, ceftriaxone 1g daily is as safe and effective as other antibiotic regimens for community-acquired pneumonia.
• However, the study by 3 suggests that ceftriaxone may not be the ideal agent for the treatment of methicillin-susceptible Staphylococcus aureus (MSSA) pneumonia, with higher clinical failure rates compared to ceftaroline or ceftobiprole.
• The study by 4 reviews the antibacterial activity, pharmacological properties, and therapeutic use of ceftriaxone, highlighting its efficacy in various infections, including lower respiratory tract infections.
• The study by 5 updates the use of ceftriaxone in the management of community-acquired and nosocomial infections, including its efficacy in pneumonia and other serious infections.
• The study by 6 emphasizes the importance of early administration of broad-spectrum antimicrobial drugs in the treatment of sepsis or septic shock, and recommends selection of antimicrobial agents based on patient factors, predicted infecting organism(s), and local microbial resistance patterns.

SOAP Note

• Subjective: The patient reports post-operative pain, cough with mucus, and hardening on the incision site.
• Objective: The physical assessment reveals hardening and tenderness around the surgical site, with laboratory results showing mild elevations in glucose and chloride levels.
• Assessment: The patient may have developed pneumonia, which requires further evaluation and treatment.
• Plan: Correlate the chest X-ray results with a CT chest, and consider empiric antibiotic therapy based on the patient's risk factors and local microbial resistance patterns, as recommended by 6.