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 should be managed with a focus on pain control, monitoring for potential complications, and further evaluation of the chest findings, as the current evidence suggests that postoperative pain management is crucial for reducing morbidity and mortality, and improving quality of life 1.

Patient Presentation

The patient is a 76-year-old male presenting to the ED with post-operative pain following a thrombectomy for pulmonary embolism removal. He has a 0.5 cm surgical wound on his left groin with approximately 1 cm of hardening around the site and tenderness when walking. He denies fever, shortness of breath, nausea, vomiting, or dizziness but reports cough with mucus since the procedure.

Laboratory and Imaging Results

Laboratory results show normal CBC values with slightly elevated glucose (128) and chloride (112). The patient is currently on Eliquis (apixaban). Chest X-ray shows an ill-defined density in the right lung with volume loss, raising concern for possible right lower lobe pneumonia.

Management

Management should include:

• Resuming pain control with acetaminophen 650-1000 mg every 6 hours as needed, as postoperative pain must be recognized and treated as soon as possible and as best as possible in all patients 1
• Continuing Eliquis as prescribed
• Obtaining a CT chest to better characterize the lung finding
• Close follow-up with both the vascular surgeon and primary care physician within 1-2 days
• The patient should be instructed to return if experiencing increased pain, redness, drainage at the surgical site, fever, or worsening respiratory symptoms

Rationale

The current evidence suggests that postoperative pain management is crucial for reducing morbidity and mortality, and improving quality of life 1. The patient's presentation and laboratory results do not suggest a surgical site infection, but rather normal healing at the surgical site. However, the chest findings warrant further evaluation to rule out potential complications such as pneumonia. Validated pain scales should be included into treatment planning, ongoing evaluation, and adjusting process 1 to ensure the patient's pain is adequately managed.

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 2, 3, 4, ceftriaxone is a effective treatment for community-acquired pneumonia, with a dosage of 1g daily being as safe and effective as other antibiotic regimens.
• 5 suggests that ceftriaxone is a useful option in the treatment of aspiration pneumonia, and is not inferior to broad-spectrum antibiotic treatment.
• 6 recommends early administration of broad-spectrum antimicrobial drugs, including ceftriaxone, for the treatment of sepsis or septic shock.

SOAP Note

• Subjective: The patient reports post-operative pain, cough with mucus, and hardening on the incision site.
• Objective: The patient has a surgical wound of about 0.5cm on the left groin, with hardening and tenderness around the site. Laboratory results and chest x-ray results are as mentioned above.
• Assessment: The patient may have developed pneumonia, possibly right lower lobe pneumonia, which needs to be correlated with CT chest results.
• Plan: The patient may benefit from antibiotic treatment, such as ceftriaxone, and further evaluation with CT chest to confirm the diagnosis of pneumonia.