I also am on call this weekend and have just consulted on a 71 yo male who is now 10 days post CABG x 3. He left the hospital in 6 days and presented to his internist the next day with SOB, sats were low 90's on RA and CXR was OK. He presented two days later with cyanosis and SOB. Labs included a platelet count of 98,000. He was admitted and diuresed but didn't improve and a V/Q scan shows multiple filling defects on the R consistent with PE. He was placed on heparin and his platelets have dropped to 29,000. He is also on steroids.
On exam he is short of breath with sats of 92% on 40% mask. He shows no signs of bleeding and has no cardiac rub. He is obese but I don't detect any tenderness in his legs other than that related to his vein harvesting. I have ordered a venous ultrasound to see if I can find a source for the clots in his lungs. A cardiac echo shows no clot in the heart. If his platelets keep dropping then the heparin will have to be d/c'd and I have been asked to place a Greenfield filter. I have no problem if I can document an inferior venacaval source. I had thought PE following bypass surgery was rare but the incidence is about 3% in a quick literature search. Anyone have any comments or thoughts. I find these heparin induced phenomena fascinating and obscure and a review of the literature isn't always that helpful.