Our patient has his d-dimer checked which is positive and has an ultrasound scan of the left leg which has confirmed a clot. On review of the images the clot is more extensive that previously. This combined with the clinical history is strongly suggestive of recurrent thrombosis.
When someone has a recurrent thrombosis it is important to think about:
- Are levels required to assess compliance and efficacy?
- Check compliance with patient
- Check correct dose, weight, taking with food (if needed), timings
- Check no medications that may reduce effect
- On other medications e.g. chemotherapy or hormones that may increase hypercoagulability?
- Looking for malignancy
- Looking for pro-thrombotic state e.g. heparin-induced thrombocytopenia (if on heparin), paroxysmal nocturnal haemoglobinuria, myeloproliferative neoplasm and anti-phospholipid syndrome
- Looking for anatomical abnormality e.g. May Thurner
Our patient now reports some upper abdominal discomfort and a CT scan reveals a mass at the head of the pancreas. Following a MDT discussion this is very likely to be a pancreatic malignancy and surgery is indicated. His surgeon recommends surgery as soon as possible and does not want to wait for more than three weeks. The surgery planned would be a Whipple’s procedure.
- How do you manage anticoagulation around elective but urgent surgery?
- What anticoagulant do you recommend?
- Any other interventions need considering?
- What about post-operatively?
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