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Heart Disease (Expert Forum)
pulmnary embolism
This forum is for questions and support regarding heart issues such as: Angina, Angioplasty, Arrhythmia, Bypass Surgery, Cardiomyopathy, Coronary Artery Disease, Defibrillator, Heart Attack, Heart Disease, High Blood Pressure, Mitral Valve Prolapse, Pacemaker, PAD, Stenosis, Stress Tests.
pulmnary embolism
by monica-le, Mar 05, 1998 12:00AM
Posted By CCF CARDIO MD - MTR on March 09, 1998 at 17:31:48:
In Reply to: pulmnary embolism posted by monica lee on March 05, 1998 at 21:00:13:
: My dad had a radical prostatectomy on Feb 9,98, in Great Falls, Montana
due to a PSA of 6.7, 1 positive biopsy out of 8. His bone scan was neg.
He had a moderately uneventful post-op course. My one concern post op
was he required oxygen 60 hrs. post op to maintain sats above 90. He is 71 years old, basically otherwise healthy, no lung disease, no heart disease, never smoked a day in his life. I am an RN; I was the only one concerned
about the extended use of oxygen. He was discharged on the 14th. His last
hct was done 2 days prior on the 12th and it was 27.3. He was given 1 unit
of autologous blood intraoperatively, and the surgeon declined giving him
any more blood prior to discharge. He was seen in the surgeon (a board
certified urologist) 10 days post op; They did not check any labs. The surgeon tried to pull out his foley, which he went home with, and it would not come out; my dad was told by his surgeon it was "stitched in" and to
come back March 10th to have it removed, as the "stitch" would dissolve by
then. He went home, became lethargic and listless the next 4 days, and
on Feb 23rd, he became acutely short of breath, and was diagnosed with a
pulmonary embolism. On admission to the Lewistown, Mt. hospital, his b/p
was 70/p, he had no urine output for approx. 4-6 hours on admission to the
ICU, and was on a Dopamine drip at 8 mcg. He was started on Heparin and
prophylactic antibiotics in case of sepsis, and had a postive VQ scan the
next morning. No further diagnostic tests, except for cxr, and doppler scan to lower extremities, were done, to my dismay. Due to a hct of 26 he was transfused with 2 units of community blood, as his autologous blood had been disposed of by now.He had a slow stable recovery, with therapeutic pt/ptt's, and discharged on coumadin 10 days later. He was discharged on room air, maintaining sats above 90, still easily fatigued and resp. rate at least 28-30. What I am especially concerned about now is he is 25 lbs. over his base weight from the surgery on Feb 9. He was given 2 doses of IV lasix 3 days post the PE, which he diuresed quite well, with upper extremities minimally swollen and edematous. He still has 2-3+ pitting edema in his lower extremities. I am concerned about kidney/lung damage.He was sent home from the hospitalthis time on no lasix,etc. I would like him to go to Billings to see aspecialist, but they are older, the "small town" medical care mentality,and I don't think they beleive me, in the seriousness of what all happened. I since requested, and reviewed his original hospital records, and he had an "event" post extubation in surgery; He had depressed st segments for 10 minutes with acute diaphoresis; It appears he had a stable airway, no difficulty breathing. The Anestheisiologist treated it with nitropaste, gave 2 doses of "Esmolol" (no tachycardia, HR was 100-108) b/p 120/80 ish.
The acute diaphoresis lasted till admission on the floor, which would have been close to 2 hrs. post op; No apparent chest pain or sob.
My questions are as follows:
1. Do you think that event post extubation was a small micro emboli?
2. How common an occurence is it for the foley cath to get stitched in?
3. Was the surgeon reasonable in not transfusing him with an hct of 27,
especially when he had 2 units of autologous blood left?
4. Am I right that it is urgent he be worked up further at a bigger
medical center for the peripheral edema, and continued shortness of
breath?
In Reply to: pulmnary embolism posted by monica lee on March 05, 1998 at 21:00:13:
: My dad had a radical prostatectomy on Feb 9,98, in Great Falls, Montana
due to a PSA of 6.7, 1 positive biopsy out of 8. His bone scan was neg.
He had a moderately uneventful post-op course. My one concern post op
was he required oxygen 60 hrs. post op to maintain sats above 90. He is 71 years old, basically otherwise healthy, no lung disease, no heart disease, never smoked a day in his life. I am an RN; I was the only one concerned
about the extended use of oxygen. He was discharged on the 14th. His last
hct was done 2 days prior on the 12th and it was 27.3. He was given 1 unit
of autologous blood intraoperatively, and the surgeon declined giving him
any more blood prior to discharge. He was seen in the surgeon (a board
certified urologist) 10 days post op; They did not check any labs. The surgeon tried to pull out his foley, which he went home with, and it would not come out; my dad was told by his surgeon it was "stitched in" and to
come back March 10th to have it removed, as the "stitch" would dissolve by
then. He went home, became lethargic and listless the next 4 days, and
on Feb 23rd, he became acutely short of breath, and was diagnosed with a
pulmonary embolism. On admission to the Lewistown, Mt. hospital, his b/p
was 70/p, he had no urine output for approx. 4-6 hours on admission to the
ICU, and was on a Dopamine drip at 8 mcg. He was started on Heparin and
prophylactic antibiotics in case of sepsis, and had a postive VQ scan the
next morning. No further diagnostic tests, except for cxr, and doppler scan to lower extremities, were done, to my dismay. Due to a hct of 26 he was transfused with 2 units of community blood, as his autologous blood had been disposed of by now.He had a slow stable recovery, with therapeutic pt/ptt's, and discharged on coumadin 10 days later. He was discharged on room air, maintaining sats above 90, still easily fatigued and resp. rate at least 28-30. What I am especially concerned about now is he is 25 lbs. over his base weight from the surgery on Feb 9. He was given 2 doses of IV lasix 3 days post the PE, which he diuresed quite well, with upper extremities minimally swollen and edematous. He still has 2-3+ pitting edema in his lower extremities. I am concerned about kidney/lung damage.He was sent home from the hospitalthis time on no lasix,etc. I would like him to go to Billings to see aspecialist, but they are older, the "small town" medical care mentality,and I don't think they beleive me, in the seriousness of what all happened. I since requested, and reviewed his original hospital records, and he had an "event" post extubation in surgery; He had depressed st segments for 10 minutes with acute diaphoresis; It appears he had a stable airway, no difficulty breathing. The Anestheisiologist treated it with nitropaste, gave 2 doses of "Esmolol" (no tachycardia, HR was 100-108) b/p 120/80 ish.
The acute diaphoresis lasted till admission on the floor, which would have been close to 2 hrs. post op; No apparent chest pain or sob.
My questions are as follows:
1. Do you think that event post extubation was a small micro emboli?
2. How common an occurence is it for the foley cath to get stitched in?
3. Was the surgeon reasonable in not transfusing him with an hct of 27,
especially when he had 2 units of autologous blood left?
4. Am I right that it is urgent he be worked up further at a bigger
medical center for the peripheral edema, and continued shortness of
breath?
Doctor's Answer
by CCF Cardio MD - MTR, Mar 05, 1998 12:00AM
Dear Monica, thank you for your question. You describe a complex situation with your
father that I hope I help clear up somewhat. I'll respond to your questions individually
and then summarize at the end.
#1) The event you describe post-extubation could be myocardial ischemia also known as
reduced blood supply to the heart muscle. During or after surgery, the heart is exposed
to great stresses from anesthesia and blood pressure changes. Your father's symptoms
were transient and more information would need to be provided for a definitive diagosis
but small microemboli are unlikely. Microemboli result only when there is an intracardiac
thrombus as the source of the emboli and it doesn't sound like that is the case in your
father. He could have coronary disease with blockages in the coronary arteries that were
not revealed until he was under stress after surgery.
#2) I don't know the answer to the question about how common a Foley catheter can be
stitched in post-operatively. I would suggest that you post this question on the Urology
Forum where a urologist could address your problem.
#3) The answer to this question is one of clinical judgement which I unfortunately don't
have because I wasn't taking care of your father. Frequently, patients hematocrits drift
down after major surgery but there is no absolute level of hematocrit below which transfuion
of blood is indicated. Each patient must be assessed individually for this problem. As
for your father, I would have to know more about him to decide what I would have done
in that setting. At our hospital, we frequently have patients after open-heart surgery
with hematocrits of 25-30% who do fine so there is no right answer.
#4) The peripheral edema and continued shortness of breath suggest the diagnosis of
congestive heart failure. It seems reasonable at this point for your father to see a
cardiologist for a complete reassessment of his condition and possibly, more tests.
Whether that needs to be done at a large medical center or closer to your home is up to
you. These symptoms might all be related to the pulmonary embolus though and that's why
I'm recommending a thorough reassessment.
The best approach here, as I already mentioned, would be to have a complete reevaluation
by a cardiologist. Your father needs coordinated medical care at this point to alleviate
his symptoms and to determine an exact diagnosis. I hope this information helps.
