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knightsbff posted 8/11/2014 14:45 PM

We got back from our FL vacay, had one day of recovery and mom showed up at my house in the AM and woke me up to look at her leg (she drove herself of course). Her entitle left leg was swollen and kind of purple. She wanted to know if she "should go to the urgent care" .

Amazingly they didn't find it on the first u/s, but positive d-dimmer and MRI show massive DVT (femoral, iliac, and great saph).

She's inpatient on Heparin. Admitting doc mentioned Xarelto, DH hasn't used it because he does emergency medicine. He is reluctant because it's new and the "other shoe" hasn't had time to fall yet.

We need prayers and info on management of massive proximal DVT. I have read everything available on uptodate, I would like to hear anyone's irl experience. And thoughts on xarelto or maybe we should do lovenox?

Help.

Dr PJ? Tushnurse? Anyone?

Pentup posted 8/11/2014 15:06 PM

Friend had this, not quite so massive, but big. Have they already put in a screen? Has she seen an interventionalist?

I don't know that med. lovenox for my friend. Long term issues because she waited to late and they could not restore flow to the main vein that was impacted.

Sending prayers for healing!

knightsbff posted 8/11/2014 15:12 PM

No filter. No interventional rad in our tiny community. Wondering if we should be considering transfer to higher level of care but not sure if it would fly for DVT???

lieshurt posted 8/11/2014 15:19 PM

Sending prayers hun

Pentup posted 8/11/2014 15:34 PM

I would transfer. If an interventionist can get that opened up, huge difference I quality of life down the road.

Also, no filter to protect lungs, etc.

If it were my parent, I would be asking for a transfer.

[This message edited by Pentup at 3:35 PM, August 11th (Monday)]

purplejacket4 posted 8/12/2014 08:50 AM

Xeralto is fine. I've used it on several patients. It's no more risky than coumadin but with no constant INR checks. You also don't have the accidental OD problem.

nowiknow23 posted 8/12/2014 08:56 AM

((((hugs)))) Keeping you all in my thoughts.

tushnurse posted 8/12/2014 10:57 AM

Yah, I'm going against PJ here on this one.
Xarelto is like Plavix in the fact that you don't know how well it is or isn't working, and there is NO quick reverse for it. With Coumadin a wallop of Vitamin K and a if needed a few FFP and good as new. It may be the old nurse in me, but I had a couple of patients that scared me and went through quite a bit of product from taking Plavix back when it was new.
With your H being an MD, and I would encourage him to talk with the PharmD he works with, and Cardiology to get their input on the thoughts on treatment.
I am a fan of the filters too. Not a big deal to place, and solves some worries. If you have an IC team there (interventional cardiology) they should also be able to place it.
Coumadin is not recommended for long term therapy for DVT's anymore though depending on size and location. If cause is known and some other factors.

sisoon posted 8/13/2014 13:34 PM

(((hugs & best wishes)))

Edith posted 8/13/2014 13:40 PM

My DD32 had a massive embolism in her mesenteric vein 6 yrs ago, was on Lovenox at first (expensive/injections), then Coumadin (constant INR checks), and finally I mentioned to her hematologist Pradaxa. He switched her, and she is doing MUCH better. No dietary restrictions like Coumadin. I would check with insurance carrier, as I believe this is still an off-label use for Xarelto, as it is for Pradaxa. They are mostly intended for A-fib patients.

Prayers for your mom. By the grace of God, I still have my DD.

E.

jo2love posted 8/13/2014 16:02 PM

Sending prayers and good thoughts.

knightsbff posted 8/13/2014 18:21 PM

Thank you all. She refused Coumadin at first but is started on it now. I too had concerns about the ability to reverse if needed. We have no (real) IC here and our one cardiologist does procedures whether they are needed or not. (He put a internal pacer in a 19 yo who was hypokalemic...)

Her DVT is massive and proximal plus idiopathic...so a candidate for long term therapy. She will follow up with vascular guy in a decent sized city an hour from us after d/c.

We appreciate the prayers and the voices of experience. I have been loosing my mind researching all this stuff and Knight has been overwhelmed at work. He's talked to everyone available here has been trying to keep his head above water at work at the same time.

She's still doing well and is in pretty good spirits. We have had some drama that I haven't had the strength to post about yet with her NPD/sociopath husband and his crackhead harem. I'm just trying to keep my focus on my mom and my family right now (kids started back to school this week).

I cancelled scouts and meetings with the church auxiliary I am heading up. I'm in survival mode at the minute and will make apologies to everyone later....

Kajem posted 8/16/2014 08:18 AM

((((((((Knightsbff)))))))))

Schadenfreude posted 8/16/2014 09:08 AM

Coumadin patient here. Other than the fact that my dose is constantly for reasons I don't understand it's no big deal. I had 9 or 10 clots in my leg and that was the only time my nephrologist got real excited. Usually he was Dr Cool, but he told me stat exam via ultrasound and gave me the option, thankfully, of immediate hospitalization or self injection with Lovenox. Ouch. But I sure didn't want to be in the hospital.

The benefit, such admit is, of dialysis,,is that blood draws are absolutely painless. They are done through a lead in the tubing leading to the machine.

I can't take Xeralto.

The lesson: it goes away. At least she didn't develop pulmonary embolism or have a stroke.

Has she seen cardiology? Atrial fibrillation, a form of irregular heartbeat, can cause blood clots. That's what happened to me. A fib is often treated with drugs.

Or maybe she was sitting too long. Any long car trips or airplane rides for her?

Jen posted 8/16/2014 17:20 PM

Xarelto is great "new" drug. The doc I work Rx's it quite a bit, as a long term management therapy. The big risk with it is bleeding, if pt is prone to bleeding, has some sort of diagnosis, then Xarelto is prolly not the best choice. Because it can't be reversed, coumadin apparently can be reversed as far as excessive bleeding goes. But barring her having a diagnosis as such or being in some sort of accident that would cause extensive blood loss, it is a great drug. PT's love it cause they don't have to have the finger checks all the time and the dosage adjusted.

There are at home testing machines for those on coumadin but they are a bitch to get approved through ins. Home health can come out and do her PT/INR checks in the home as long as she stays home health qualified.

I don't know much about inpatient treatment - They may start discuss placing a filter, there has been some recent controversy over one of the filters that are used, and I believe it is the one in the area of her DVT, but I'm not sure.

An internal medicine doc would be my choice for her PCP and a cardi doc who specializes in DVT's and clots ect ...

(((hugs)))

purplejacket4 posted 8/16/2014 17:29 PM

Xeralto IS FDA approved to treat DVTs. With Pradaxa it is off label.

Believe me if someone has insurance we use Xeralto. Yes it has bleeding risks but I've had several people DIE because they fell or were in a car wreck and they bled out too fast to give them Fresh frozen plasma (which reverses coumadin immediately) or vitamin K that takes days. But hey don't trust me I'm just a physician who practices actual hospital medicine and just spent the last two weeks treating this VERY thing. And I'm pissy too.

Jen posted 8/16/2014 18:06 PM

Well alrighty then ....... the Dr. has spoken and I will quietly go back in my LPN hole.

Hugs and prayers to you and yours, I really hope they find what works best for her and quick resolution.((()))

purplejacket4 posted 8/16/2014 18:32 PM

Sorry Booger Bear. I just figured out a forgot to take my celexa last night. Boy am I a bitch today.

inconnu posted 8/16/2014 21:49 PM

(((knightsbff))) can only offer hugs, not advice. but know I'm keeping y'all in my thoughts.

knightsbff posted 8/18/2014 15:09 PM

She was discharged from the hospital Saturday and is staying with me for a while. We follow up with her MD on Thursday and I think he plans to refer her to a vascular surgeon.

The swelling in her leg has gone down some but now it's starting to be uncomfortable at the sight of the clot and she's having pins and needles sensation in the leg and foot. Before it was just numb. She also says she's happy she can feel the floor under her foot again. Hope these are good signs...

Thank you for the prayers, advice, positive thoughts, and hugs.

Dr. PJ, I think he may change her to Xeralto after 3 months... We will discuss it with him when we see him.

I'm working on menu planning right now...for a diabetic, on Coumadin, with hyperlipidemia. Any dietitians with two weeks of meals planned out for someone with these dietary needs?