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BKA following a hysterectomy, it really happened

Specializes in OB, M/S, HH, Medical Imaging RN.

I have a patient who had surgery. We got a call to go out to her home and check her PT/INR twice a week for several weeks until her coumadin was adjusted. A few minutes later I get a call that her DC was cancelled and she was going back to surgery for an amputation! Her history was that she had a PE last year and has been on coumadin since. Her doc told her to quit taking her coumadin a week before her surgery. Her PT/INR was not checked before or after surgery. On the third day post op when she was supposed to go home her right foot started hurting and getting dark. She ended up with a below the knee amputation of her right leg. I understand stopping the coumadin before the surgery but not checking her blood (I thought clotting time PT and PTT were mandatory before OR?) and not restarting the coumadin after surgery? Any thoughts?

maolin

Specializes in IMC, ICU, Telemetry.

My first thought, as a recovered DVT patient myself, is why didn't the patient followup on the coumadin therapy after surgery. If she has hx of PE and is on long-term/possible lifelong coumadin therapy, I'd think she would have asked about it - either her GYN surgeon or the doctor managing her coumadin (vascular or hematologist?). I was getting blood checks q1-2weeks toward the end of my therapy. There was rarely a time I didn't think about the meds or the clot or the blood draws. I have to imagine that after living through PE and undergoing such major surgery, it would be even more on my mind.

This is not to say the doctor(s) didn't have a responsibility to followup and resume the coumadin - but I wonder if/why the patient didn't ask about it.

psychonurse

Specializes in ER, ICU, Corrections.

I would think that it would have been checked before she had the surgery and post op to make sure that she wasn't having any bleeding problems. That bleeding time stuff scares me sometimes and some people are so complacent with it. I know that when I was taking it after my total knee it scared me to death thinking that I was going to bleed to death at any time....

DutchgirlRN, ASN, RN

Specializes in OB, M/S, HH, Medical Imaging RN.

I don't understand either why she didn't question her doctor sooner and also I thought for sure that a PT/INR or at least a bleeding time was a prerequist for OR?

prmenrs, RN

Specializes in NICU, Infection Control.

Please be careful about HIPAA issues here! It might not be all that difficult to figure out who/what hosp you're discussing. Thanks.

DutchgirlRN, ASN, RN

Specializes in OB, M/S, HH, Medical Imaging RN.

Please be careful about HIPAA issues here! It might not be all that difficult to figure out who/what hosp you're discussing. Thanks.

We could say that about any post in which we discuss what happened with our patients and ask for opinions. I truely do not even know what hospital she was in or which city she was in or who her doctor was.

My first thought is big-time lawsuit coming up!

I also thought PT/PTT were mandatory pre-op, and certainly should have been followed post-op.

I've known an amazing number of patients who didn't think they had any need to worry about their meds, especially when hospitalized, as that was the doctor/nurses responsibility. And while I think she should have checked on it also, I do think it was foremost the docs place to make sure his/her patient was getting the proper meds.

Wouldn't be surprised if they tried to blame the nurses for not being sure she got those meds and labs post op. After all, aren't we usually the fall guys when the you-know-what hits the fan?

WOW Is all I can say. I take care of "hysts" all the time. I guess I would want to know more here to form my opinion really. But I can say, how tragic this is!

Marie_LPN, RN, LPN, RN

Specializes in 5 yrs OR, ASU Pre-Op 2 yr. ER.

We could say that about any post in which we discuss what happened with our patients and ask for opinions. I truely do not even know what hospital she was in or which city she was in or who her doctor was.

Right, but because a BKA following a hysterectomy isn't that typical, making it easier for anyone to figure out where this happened, might be what prmenrs meant.

Anyway,

I thought clotting time PT and PTT were mandatory before OR?)

It is where i work.

I have a patient who had surgery. We got a call to go out to her home and check her PT/INR twice a week for several weeks until her coumadin was adjusted. A few minutes later I get a call that her DC was cancelled and she was going back to surgery for an amputation! Her history was that she had a PE last year and has been on coumadin since. Her doc told her to quit taking her coumadin a week before her surgery. Her PT/INR was not checked before or after surgery. On the third day post op when she was supposed to go home her right foot started hurting and getting dark. She ended up with a below the knee amputation of her right leg. I understand stopping the coumadin before the surgery but not checking her blood (I thought clotting time PT and PTT were mandatory before OR?) and not restarting the coumadin after surgery? Any thoughts?

Wow... there were several other options available to the doc vs. just stopping coumadin. LOVENOX anyone??? What is wrong with some docs! You stop Coumadin about a week before surgery, start Lovenox, hold the day before and day of surgery, start Lovenox and Coumadin the day after surgery, watch PT/INR until appropriate and stop Lovenox. This is a no brainer for nurses, why is it difficult for some docs?

P_RN, ADN, RN

Specializes in ORTHOPAEDICS-CERTIFIED SINCE 89.

I agree w/ SBE. There is a lot I'd need to know before I'd form an opinion. This is one reason that I wish we could go back to the day before surgery admissions.

I have had a PE also and it is always on my mind. These days, preop, you answer the same question over and over and over and over ad nauseum.

We don't know if the patient ever told anyone preop. We don't know that the GYN knew. We don't know who cleared her for surgery....there are too many unknowns.

This is a very sad story with a very sad ending.

DutchgirlRN, ASN, RN

Specializes in OB, M/S, HH, Medical Imaging RN.

Wow... there were several other options available to the doc vs. just stopping coumadin. LOVENOX anyone??? What is wrong with some docs! You stop Coumadin about a week before surgery, start Lovenox, hold the day before and day of surgery, start Lovenox and Coumadin the day after surgery, watch PT/INR until appropriate and stop Lovenox. This is a no brainer for nurses, why is it difficult for some docs?

You took the words right out of my mouth. I couldn't agree more.

DutchgirlRN, ASN, RN

Specializes in OB, M/S, HH, Medical Imaging RN.

This is a very sad story with a very sad ending.

It is very sad but I'll tell you the patient sure isn't. She unbelieveably upbeat. Just days after being at home she was on crutches cooking dinner. She says once she gets her new leg she'll be right back to her old life, driving, working, etc. She went to every Christmas party she was invited to because she's determined not to let this change her life in anyway. I really admire her attitude and I believe she will accompolish everything that she goes after.

DutchgirlRN, ASN, RN

Specializes in OB, M/S, HH, Medical Imaging RN.

Please be careful about HIPAA issues here! It might not be all that difficult to figure out who/what hosp you're discussing. Thanks.

I see your point I'll be more careful with the details.

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