Re: radical prostatectomy

Posted By HFHS M.D.-MS on March 06, 1998 at 16:19:59:

In Reply to: radical prostatectomy posted by monica lee on March 05, 1998 at 20:56:50:








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?  



          





    


Dear Monica
Thank you for your questions.
Sounds like your father has had a run of  tough luck.
First,  I do not have a right to question the judgment of the urologist or anesthesiologist.   Today, we were not able to duplicate the exact same clinical scenario and re-ask the same questions to see if things might have been done differently.  Hind Sight - 20/20 applies.  As you know, medicine is not an exact science in fact it is more of an art. It is possible to have multiple correct decisions, given the same scenario, in medicine.   Who knows what was the urologist considering when he made the decision not to transfuse. Transfusions are not without risk. It is not impossible that your father could have received the wrong blood due to clerical error if the autologous units were ordered.  I have seen patients spike high fevers with transfusion of their own blood!  Medicine today is more of an  informed consent and group decision making process.  If you felt the decision not to transfuse was a bad one, the best time to discuss it is not now after the fact.  Finally, many urologists will not transfuse autologous blood any quicker than banked blood and a hematocrit is only one of the many parameters used to make that clinical decision.
Catheters can be easily stitched  during the procedure.  The surgical technique used to  place sutures from the bladder to the urethra requires the needle be passed immediately along side the catheter.  Another explanation is that suture may be tied around the catheter as opposed to along side it.   It can be very difficult to tell if the stitch incorporates the catheter  until is it time for the foley  to come out.  There is probably  an increased awareness of the retained catheters now  because of  a movement to  remove the catheters earlier in the post operative course.  To answer your question, it does happen but not very often at HFH. The alternative to waiting for the suture to dissolve would be to forcibly twist and pull on the catheter in an attempt to free it:  this may be traumatic and is probably contraindicated for a patient on coumadin.  
We do know that EKG changes are seen with pulmonary emboli,  but not all the time.  A heart attack is also high in the differential diagnosis. Blood clots are common in pelvic surgery. Most surgeons place sequential compression hose around the legs before anesthesia, use subcutaneous injected heparin or elastic continuous compressive leg hose  if the risk of deep vein thrombosis is high.  Cancer does increase the risk of DVT as well as obesity, immobility and recent trauma/ surgery.  In the lung, the blood clots are usually reabsorbed and the lung recovers function over time.    If your father shows signs of congestive heart failure or fluid overload, ( distended neck veins , shortness of breath,  fluid on the lungs heard with stethoscope or frothy sputum),  he may benefit from medical treatment. Remember if given lasix, the potassium needs to be followed or empirically replaced. Almost all patients are able to mobilize peripheral fluid accumulation after surgery if given time ( one month).  Keeping his legs elevated when he is seated will help.  Doppler US of the leg veins may show where the clot started from and may show some residual.  If the pulmonary embolus came form the pelvis, the US will not be able to identify if there is residual clot still present..  If residual clot is present in the leg or pelvis, this can be a cause of lower extremity fluid swelling (edema).   Until the legs can develop collaterals ( bypass channels)  stocking hose and  leg elevation is the treatment.
I am not sure about the concerned for kidney failure unless its relation  to the accumulation of fluid.  Kidney failure is probably not of concern unless his serum creatinine is elevated.
Extended oxygen use is a concern if the percent inhaled oxygen is at very high concentrations.  ( > 60-80%)   These percentages are usually seen when a patient is on significant ventilator support or non rebreather mask. At these high concentrations, time of exposure is a factor and weaning is a consideration  after about 2- 3 days.
I always encourage second opinions if well founded.   They can offer a different perspective,  peace of mind and further patient education / understanding.  
Hope this helps.
More individualized care is available at the Henry Ford Hospital and its satellites (1 800 653 6568). We can also arrange local accommodations through this number if this is your need. Please bring any physicians notes and lab test results that
you may be able to obtain. These will help us greatly.
This information is provided for general medical education purposes only.  Please consult your physician for diagnostic and treatment options pertaining to your specific medical condition.
Sincerely;
HFHS-M.D. MS
* Keyword: Pulmonary embolus, high concentration oxygen therapy, Deep vein thrombosis, difficult catheter removal