What exactly is an embolism? It is a blood clot carried in the blood vessel. A pulmonary embolism is a blood clot that has gone to the lungs. The risk for pulmonary embolism, PE, is high in patients over 40 years old who have a history of vein problems called phlebitis, a surgery lasting longer than an hour, and with orthopedic procedures on the hips and knees. There is a also high risk after trauma, especially if veins or surrounding tissue have been badly injured.
What should your doctor do to prevent this problem? First of all is the awareness of the problem. Second is an anticipatory treatment of the patient before it occurs. This means applying special stockings or compression apparatus during many surgical procedures. In the very obese or high risk patient, the physician may want to give the patient prophylactic anticoagulant treatment.
The most common anticoagulant is heparin or a similar drug, and one should get repeated blood tests (see Chapter 25) to make sure that the blood is “thin” enough. The patient may be changed over to a pill, coumadin, which can be taken daily at home. The physician must carefully monitor even this drug, for if the blood gets too thin, the patient can bleed massively from the slightest injury to the intestinal tract or the urinary tract.
What are the symptoms of formation of clots in the larger veins deep in the leg? There may be no warning signs and that is the greatest danger, but most of the time the patient will have aching in the leg, a tender cordlike mass when the clot is in the vein, swelling of that leg and occasionally redness, fever and pain on motion. If the patient has already progressed to pulmonary embolism, and it may only be a small blood clot at first, the signs and symptoms include sudden chest pain, shortness of breath, coughing up blood, rapid heart rate, and falling blood pressure. If it is a large embolism, shock and death may occur rapidly!
The physician listening to the heart and lungs can sometimes hear abnormal sounds with pulmonary embolism. If a patient has symptoms even remotely suggestive of thrombus or embolism, the nurse should immediately notify the physician and certain diagnostic tests should be done immediately. Better to have several negative tests than miss a positive one! There are several tests, but three are of major importance. The first, is called ultrasonography, a sound wave study that can show blood clots in a vein. The second is a lung scan in which a picture of normal and abnormal lung can be determined by injecting and breathing in radioactive materials with very low radioactivity and studying a special xray afterwards. The third test is the most specific for embolism and consists of doing an arteriogram, or xray of the vessels in the lung using intravenous dye.
If any of these are positive, then anticoagulation therapy is started immediately. unless there is a contraindication to using a blood thinner, such as bleeding in an organ such as the brain, abdomen or intestine. In that case, the physician may opt to place a filter in the big vein in the abdomen to prevent large blood clots from getting to the lungs. This filter, can either be placed by a radiologist through a vein in the neck or groin called the Greenfield Filter, or can be applied through a surgical incision, the AdamsDeWeese or Miles inferior vena caval clip.
Chapter 20
DIABETES MELLITUS AND SURGERY
In your pancreas, there dwells,
An area filled with Langerhans cells.
These cells called islets, so very small,
Produce insulin, as you may recall.
This insulin is what your body needs,
To use the sugars in tiny beads.
Without the insulin, you may be sweet,
But your cells are getting nothing to eat.
In diabetes the islet cells,
For some strange reason, don't work so well,
And if insulin is not produced,
Glucose in your blood's not used.
So let's give three cheers to Banting and Best,
The two researchers that made the test,
And discovered insulin in dogs one day.
So you can enjoy a hot fudge Sundae.
Diabetes Mellitus is a strange disease, and it affects 23% of the populace. Whether you have childhood or adult onset diabetes, your body has a problem with the islet cells of the pancreas, and they don't produce enough insulin, a word derived from the Latin word “insula,” for island or islets. The insulin helps metabolize and mobilize sugars from your blood into your tissue. Some diabetics may be entirely diet- controlled because they apparently have some insulin, whereas others are reliant on daily injections of one of the many types of insulin available, or they may take some other medication that mimics the effect of insulin.
Just to digress for a moment, when a person has high blood pressure or hypertension, controlling the blood pressure with medications completely corrects the problem. If there is no high blood pressure, it usually means there are no problems related to hypertension!
Unfortunately, the situation with diabetes mellitus is more complex than just elevation of the blood sugar. Even if the diabetic patient maintains his blood sugar at a normal level with diet or other means such as insulin, the disease of diabetes mellitus may still progress, affecting different organs in your body. It is in the latter context that the diabetic patient becomes of concern to the surgeon. Diabetes affects the small blood vessels, narrowing them and decreasing the blood supply to the hands and feet or the vessels in the heart and may lead to tissue damage in these areas, necessitating bypass surgeries (see Vascular Surgery). If very severe and not well managed, amputations of the toes or even a leg may be necessary. Because of the injury to microscopic vessels in the skin, the diabetic may have poor healing of skin wounds and surgical incisions may heal more slowly, with greater chance of infection and wound separation. Somehow the effect on the skin also involves the sensory nerves, and diabetic patients may develop abnormal nerve function and numbness, called neuropathies, in the toes and feet. If the diabetes affects the eyes, a condition called diabetic retinopathy can occur and lead to poor vision or blindness.
Diabetes mellitus is a strange and wide-affecting disease. What are the surgical considerations, and why do I give a whole chapter to the subject? First, the surgeon and anesthesiologist must carefully monitor the blood sugar during the stress of surgery; surgery is a stress both emotionally and physiologically! If the blood sugar gets too low, (hypoglycemia), then not enough sugar is getting to the brain cells and seizures or brain damage can occur. If the blood sugar gets too high, (hyperglycemia), then a serious condition called diabetic ketoacidosis can occur with severe tissue consequences and even death.
The surgeon knows that, because of the diabetic effect on tissue, there is poorer blood supply to tissue and skin and thereby a greater chance for wound infections (see Wound Healing chapter), slower healing, and more complications. Whereas, we usually take out skin sutures after seven to ten days, in the diabetic I may wait twice as long! Sores and ulcers that heal rapidly in the nondiabetic may become a complex lingering problem in the diabetic patient, and even skin grafting will have poorer results.
Patients who have blood vessel problems from hardening of the arteries or arteriosclerosis, or secondary to smoking will have even more problems if they are diabetic. In the diabetic patient with vascular disease, if they don't stop smoking, the outlook for saving a foot or leg is very poor! The diabetic needs to take exquisite care of his skin, and whenever there are even minor cuts or bruises he should seek out medical attention immediately.
New research with pancreas transplants may offer some wonderful treatment options in the future but this work is still embryonic in the transplantation