As a hospitalist I routinely see patients with venous thromboembolism including many patients requiring initial ICU care, including patients with obesity. Avoidance of this outcome is not always possible but the three obvious options in this case are:a) better monitoring b) an IVC filter given the large existing PE and remaining DVT threatening PE and c) a non-heparin anticoagulant.
Symptoms and history do not necessarily indicate anticoagulant inappropriateness – since severe PE can happen with any treatment, many PE patients lack a provocation. This circumstance is fairly common given the unpredictability of heparin, perhaps compounded by weight, and its management depends on the details. If she was mildly sub therapeutic, switching to another product like LMWH may actually have been a smart strategy, because antithrombin deficiency is quite rare, most providers have never seen it, and simple problems with heparin drips are common. If she was suspiciously unsuccessful with the heparin drip then this could have been recognized as a clue for antithrombin deficiency. Pharmacy or hematology consultation may have been appropriate in either case. If evidence of an unusual course was sufficient, then the patient could have been switched to an alternative agent like argatroban or rivaroxaban. Her main treatment options before death were IVC filter placement and thrombolysis. IVCF use in this situation is of marginal benefit (no mortality reduction overall immediately or after years; a tradeoff between PE and DVT), but relatively common and has a physiologic rationale–in this case, a patient who likely could not have tolerated another PE. Thrombolysis was recently found to have a favorable risk-benefit profile in a meta-analysis, which found reduced death compared with bleeding risks, in the setting of intermediate risk pulmonary emboli. Its use has not become standard of care, however, because of some issues with the study. However, given the reported decline in the patient’s status, reconsideration of therapy should have occurred. Thrombolysis as a rescue strategy is the obvious and well known back up plan to up front anticoagulation.
