Pulmonary thromboembolism clinical pathway
A. Standard hospitalization process of pulmonary thromboembolism clinical pathway
(A) Applicable objects.
The first diagnosis of pulmonary thromboembolism (ICD-10: I26, 001/I26, 901)
(B) Diagnostic basis.
According to the Clinical Diagnostic and Treatment Guide-Respiratory Pathology Sub-volume (compiled by the Chinese Medical Association, People’s Health Publishing House), the Guidelines for the Diagnosis and Treatment of Pulmonary Thromboembolism (Draft) (Chinese Medical Association, Respiratory Pathology Branch, 2001)
1.Clinical manifestations may include dyspnea, chest pain and hemoptysis.
2.Risk factors of pulmonary thromboembolism such as deep vein thrombosis may be present.
3.The diagnosis can be confirmed by one or more of the following tests being positive.
(1) CT pulmonary arteriogram (CTPA): showing a low-density filling defect within the pulmonary artery, partially or completely surrounded by opaque blood flow, or showing a complete filling defect.
(2) magnetic resonance pulmonary arteriography (MRPA): demonstrates a low-density filling defect within the pulmonary artery, partially or completely enclosed between opaque blood streams, or a complete filling defect.
(3) Nuclear pulmonary ventilation and perfusion scan: shows a pulmonary perfusion defect distributed over lung segments and does not match the ventilation picture, i.e., a localized perfusion defect in at least one or more lobe segments while the site is well ventilated or without abnormalities on X-ray chest radiographs.
(4) Selective pulmonary arteriography: finding direct signs of PE, such as intravascular contrast filling defects in the pulmonary vessels with or without orbital signs of flow blockage.
(5) Echocardiography: detects thrombus in the proximal pulmonary artery.
(4) The following diseases need to be excluded: such as primary pulmonary artery sarcoma, amniotic fluid embolism, fat embolism, air embolism, infectious thrombosis, etc.
(C) The choice of treatment plan.
According to the Clinical Diagnostic and Treatment Guidelines-Respiratory Diseases Branch (edited by Chinese Medical Association, People’s Health Publishing House), “Guidelines for the diagnosis and treatment of pulmonary thromboembolism (draft)” (Chinese Medical Association, Respiratory Diseases Branch, 2001)
1.General management, hemodynamic and respiratory support.
2.Anticoagulation and thrombolytic therapy.
3.Other treatment measures: surgical embolization, transvenous catheter fragmentation and aspiration of thrombus, placement of vena cava filter, etc.
(D) Standard hospitalization days: (high-risk) 10-14 days, (medium- and low-risk) 7-10 days.
(E) Entry pathway criteria.
1.The first diagnosis must be in accordance with ICD-10: I26, 001/I26, 901 pulmonary thromboembolism disease code.
2.When the patient has other disease diagnosis at the same time, but does not need special treatment during hospitalization nor does it affect the implementation of the clinical pathway process of the first diagnosis, it can enter the pathway.
3.Conditions that obviously affect the routine treatment of pulmonary thromboembolism are not entered into the clinical pathway of pulmonary thromboembolism.
(F) Day 1-3 after admission.
1.Required examination items.
(1) Routine blood, routine urine and routine stool.
(2) Liver and kidney function, electrolytes, blood gas analysis, blood type, coagulation function, D-dimer, infectious disease screening (hepatitis B, hepatitis C, syphilis, AIDS, etc.).
(3) Troponin T or I.
(4) Chest X-ray, electrocardiogram, echocardiogram, bilateral lower extremity venous ultrasound.
2.One of the following relevant tests can confirm the diagnosis: CT pulmonary arteriography, nuclear pulmonary ventilation and perfusion scan, magnetic resonance pulmonary arteriography, selective pulmonary arteriography.
3.According to the patient’s condition, the following can be selected if available: BNP, immune index (including cardiolipin antibody), protein S, protein C, antithrombin III, etc.
(vii) Select the medication.
1.Thrombolytic therapy: urokinase, streptokinase, recombinant tissue-type fibrinogen activator.
2.Anticoagulation therapy: heparin, low molecular heparin, warfarin, etc.
(H) Discharge criteria.
1.Stable vital signs.
2.Adjustment of the international standardized ratio (2,0-3,0).
3.No complications that require continued hospitalization.
(ix) Variation and cause analysis.
1.Complications occurred during the treatment.
2, accompanied by other diseases, requiring relevant diagnostic treatment