What is the management approach for a patient experiencing orthopnea one week post femoral fracture surgery?

Orthopnea One Week Post Femoral Fracture Surgery

Immediately evaluate for pulmonary embolism (PE) and heart failure, as orthopnea one week post-surgery is a red flag for life-threatening cardiopulmonary complications that require urgent diagnostic workup and treatment.

Immediate Diagnostic Approach

The differential diagnosis for orthopnea in this setting is narrow but critical:

• Pulmonary embolism is the most concerning diagnosis, given that DVT prevalence is 37% and PE prevalence is 6% in hip/femoral fracture patients, though clinical symptoms appear in only 0.5-3% of cases 1
• Acute heart failure or decompensation of pre-existing cardiac disease, particularly if the patient has unrecognized calcific aortic stenosis or left ventricular dysfunction 1
• Pneumonia or chest infection, which is common in the postoperative period and may present with respiratory symptoms 1
• Fat embolism syndrome, though this typically presents earlier (within 24-72 hours) and would include additional features beyond orthopnea 2

Urgent Workup Required

Obtain the following immediately:

• Arterial blood gas to assess oxygenation and acid-base status
• D-dimer (though may be elevated post-operatively, a negative result helps exclude PE)
• CT pulmonary angiography if PE is suspected based on clinical presentation and oxygen saturation
• Chest X-ray to evaluate for pneumonia, pulmonary edema, or pleural effusion 1
• ECG to assess for cardiac ischemia or arrhythmias 1
• Echocardiography if heart failure is suspected or to evaluate right heart strain from PE 2
• Pulse oximetry and monitor oxygen saturation continuously 1

Management Based on Diagnosis

If Pulmonary Embolism is Confirmed:

• Anticoagulation with heparin is the standard treatment, though this must be carefully balanced against bleeding risk one week post-surgery 2
• Consider inferior vena cava filter placement if anticoagulation is contraindicated due to recent surgery or bleeding risk 2
• Supplemental oxygen to maintain adequate saturation 1
• Thrombolysis is generally contraindicated in the immediate post-surgical period unless the patient is hemodynamically unstable 2

If Heart Failure is Identified:

• Diuretic therapy to reduce volume overload
• Supplemental oxygen administration 1
• Optimize fluid balance, as hypovolemia is common but fluid overload can also occur 1
• Address any precipitating factors such as atrial fibrillation (target ventricular rate <100 bpm), hypokalemia, hypomagnesemia, or silent myocardial ischemia 1

If Pneumonia is Present:

• Prompt antibiotic therapy based on local protocols 1
• Supplemental oxygen and intravenous fluids 1
• Physiotherapy to improve respiratory function 1
• Early mobilization to improve oxygenation and respiratory function 1

Supportive Care Regardless of Etiology

• Administer 100% oxygen initially, then titrate to maintain adequate saturation (older patients are at high risk of postoperative hypoxia) 1
• Optimize fluid status: Hypovolemia is common postoperatively, but avoid fluid overload in the setting of cardiac or pulmonary compromise 1
• Continue thromboprophylaxis with fondaparinux or low molecular weight heparin if not contraindicated by active bleeding 1
• Adequate analgesia with regular paracetamol and carefully titrated opioids, as pain can contribute to respiratory compromise 1
• Monitor for postoperative cognitive dysfunction, which occurs in 25% of hip fracture patients and may complicate assessment 1

Critical Pitfalls to Avoid

• Do not dismiss orthopnea as "normal" post-surgical discomfort—it represents significant cardiopulmonary pathology until proven otherwise
• Do not delay imaging if PE is suspected; intraoperative PE can be life-threatening and post-operative PE remains a significant risk 2
• Do not assume thromboprophylaxis prevents all thromboembolic events—clinical PE still occurs despite prophylaxis 1
• Avoid fluid overload when treating presumed hypovolemia, as this can precipitate or worsen heart failure 1
• Consider silent myocardial ischemia as a cause of acute decompensation, particularly in elderly patients with multiple comorbidities 1