Help w/Hypoxia - patient sent home....

[Kansas_RN]

Help me out here. I posted this in General Forums without any response.

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I have a question for all of you. I had a patient last week. She had TAH with vertical abdominal incision. She did very well, but had one problem. Hypoxia. I personally don't like hypoxia in my patients. It makes me nervous. Anyway she could get up and walk without sats dropping, (at least not that we documented it seemed she was breathing deeper) but in her room and especially at rest she would desat to mid 80's and become symptomatic. (Nausea, sob, lightheaded). The surgeon did PE tests (EKG, CXR, US Bilat lower extrem for clot, and d-dimer) and consulted her PCP. All tests were neg, even the d-dimer two days after surgery, which was a surprise to me.

Most of us thought it was her epidural, but even 24hrs after turning it off she was having symptomatic episodes. Nurses were concerned. Lungs clear. CXR (port) showed mild ataletesis with clearing the next day. (post-op day 3). Her doctor almost seemed to be annoyed that he was bothered to be consulted by this. The first time in her room he took a pulse ox in and found her sitting up eating without oxygen on and sats were 87% and she was starting to become SOB. They dropped as low as 84% was documented more than once on several shifts. He commemted he would like a "sleep study on her after she's out of the hosptial....maybe she has sleep apnea and she might run low." But all of these time she ran low she was awake and sometimes talking to staff and visitors for over 30min before checking her sats.

The next day the doc stated if you check her sats and they are normal just don't check them again. And that same day stated that she could go home if the surgeon dismissed her...which he did.

My patient in question is a nurse and a friend and was insulted at the way the physician treated her, acting like this was "just an annoyance" in her words. She left post-op day 3 and continued to have these episodes for 3 more days as home. After that time she hasn't had any problems with the symptoms.

My question...have you had a patient go home with these symptoms. I'm not saying she had a PE, because the d-dimer was neg....but something was going on. Can you give me your opinions on this?

[Tweety, BSN, RN]

Interesting. I don't have an opinion, but perhaps she should see pulmonologist or cardiologist to help get to the botttom of it.

[rn/writer, RN]

If she's no longer having these spells, it might be difficult to pin down their cause after the fact.

As I read your post, I wondered whether there was a postural or positional component to the desatting. Especially with the atelectasis. It would have been interesting to draw an ABG or two during the desats.

I'm glad your friend is better now. I hope she speaks to her doc about his seeming impatience. She's more in a position to give him feedback (and be taken seriously) on his "alteration in bedside manner" than most people would be. Maybe he didn't know he was letting his frustration show--and he needs to.