Management of Post-Operative Patient with Wound Dehiscence and Pulmonary Embolism
The patient with wound dehiscence and pulmonary embolism after major abdominal surgery requires immediate oxygen therapy, anticoagulation with heparin, and appropriate wound management, along with careful respiratory monitoring and support.
Initial Assessment and Management
Respiratory Management
- Administer supplemental oxygen immediately to maintain SaO2 ≥90% as the patient is experiencing respiratory distress with gurgly and wheezy chest sounds 1
- Consider high-flow oxygen via nasal cannula if conventional oxygen supplementation is insufficient 1
- Non-invasive ventilation should be preferred over intubation when possible, as mechanical ventilation may worsen right ventricular (RV) failure in PE patients 1
- If intubation becomes necessary, use tidal volumes of approximately 6 mL/kg lean body weight and apply positive end-expiratory pressure cautiously 1
Pulmonary Embolism Management
- Initiate anticoagulation with intravenous heparin immediately after confirming PE diagnosis 2
- Adjust heparin dosage according to activated partial thromboplastin time (aPTT), targeting 1.5-2 times normal 2
- Monitor coagulation status (aPTT, INR, platelet count) at baseline and approximately every 4 hours initially 2
- Risk stratify the patient using validated tools such as PESI or sPESI to guide treatment intensity 1
- Assess for RV dysfunction using imaging (echocardiography or CT) and laboratory biomarkers (cardiac troponins or natriuretic peptides) 1
Wound Dehiscence Management
- Perform wound assessment under sterile conditions to determine the extent of dehiscence 3, 4
- If bowel is protruding from the wound, immediate surgical intervention is required 4
- For non-emergent wound dehiscence:
- Maintain a moist wound environment 4
- Reduce bioburden with appropriate wound care and antibiotics if infection is present 3, 4
- Consider wound stapling as a potential treatment option for managing dehiscence 3
- Monitor for signs of wound infection which may complicate both wound healing and PE management 5, 4
Ongoing Monitoring and Care
- Regularly monitor vital signs, oxygen saturation, and respiratory status 1
- Perform periodic platelet counts, hematocrit, and occult blood in stool during heparin therapy 2
- Be vigilant for bleeding complications from anticoagulation, particularly at the surgical site 6
- Monitor for signs of recurrent PE, which occurs in approximately 1% of patients 6
- Ensure adequate nutrition to support wound healing and recovery 4
Special Considerations
- Balance the need for anticoagulation against the risk of bleeding at the surgical site 6
- The mortality rate for patients with wound dehiscence can be 14-50%, and PE further increases mortality risk, requiring aggressive management 4
- Long-term bed rest, recent surgery, and wound infection are risk factors for PE that are all present in this patient 5
- Consider the timing of wound debridement and other interventions in relation to anticoagulation therapy 5, 6
Follow-up Care
- Plan for transition from intravenous to oral anticoagulation when appropriate 2
- Arrange for re-evaluation of PE status 3-6 months after the acute event 7
- Monitor for development of incisional hernia, which occurs in up to 43% of patients with wound dehiscence 4
This comprehensive approach addresses both the acute respiratory compromise from PE and the wound healing complications, with careful consideration of how each condition impacts the management of the other.