Post CABG patient has to go back to the OR!! Question about blood test levels

[helpnurse]

my day at work-----

70 y.o male transfered to sdu with cabg x 3 post-op day 9

after or patient mentioned to md that he hears a clicking sound when he breathes (as if he had a pacemaker)

no intervention taken yet, as per md will wait and see

:patient has slight sob at rest and increased sob on exertion 4-5 l np@ 95% rr 22-24

:post-op complications are hypotension - treated with levophed in icu

:went into a-fib 3 times, treated with amnio i.v, presently bradycardia at 55bpm amnio held.

:positive sputum culture for psudemonas, etc

:pleural effusion, treated with a thoracentisis (tap) at bedside- removed 1 litre of serousangionous fluid.

:patient stated his breathing was much better and felt good but this was only temporary, the next day he went

back to having sob

:treated with timentin and vanco iv for pnemonia and possible sternum infection, increased wbc, sternum oozing moderate amount of blood, patient remains afebrile.

:m.d tells patient his sternum is unstable/ broken and he has to go back to or to re-wire his sternum (so that's why the patient heard a clicking noise)

here is my question:

his platlets are panic high, (499) increasing every day. won't you bleed out if your platlets are too high, being that he's going to or? i asked the nurse practioner and she said no. "if your plat count is high you are likely to clot, if your plat count is too low you are likely to bleed out.. is this true? now this is where i'm confused because when patient's have pacewires the doctor won't remove it if the inr is too high. they only remove it if the inr is less then 1.5.......she also said it is normal for his platlets to increase because he has a lung infection...is this true?

oh i forgot to mention this...bp 129/50 hr 59....gave 50mg of metropolo and 2.5mg of ramipril. asked nurse practioner and she said it was ok to give...4 hours later hr droped to 35-45, patient asymptomatic, md paged, i hooked up external pacemaker pads to patient just in case he went back down to 35bpm.. but he didn't thank god. tomorrow i will find out how the or went

this is a learning experience for me, hopefully it will helpsomebody eles

would appreciate any responses...thanks

[tothepointeLVN, LVN]

Platelets and INR are two different things.

Platelets are what clots your blood when cut. Too many platelets your blood will clot more.

INR is the measure of how long it takes your blood to clot. The higher the value the longer it takes to clot.

[moonshadeau, ADN, BSN, MSN, RN, APN, NP, CNS]

question- uri prior to surgery? was there a clicking sound audible on his physical exam? respiratory versus cardiac. occasionally, you can hear a split s3 on a patient with a possible clot in the atrium.

:patient has slight sob at rest and increased sob on exertion 4-5 l np@ 95% rr 22-24

:post-op complications are hypotension - treated with levophed in icu

:went into a-fib 3 times, treated with amnio i.v, presently bradycardia at 55bpm amnio held.

i probably would have said that he was dry and probably has a pleural effusion

:positive sputum culture for psudemonas, etc

:pleural effusion, treated with a thoracentisis (tap) at bedside- removed 1 litre of serousangionous fluid.

ha. i guessed right on the pleural effusion, but it is a pretty common complication after cabg surgery.

:patient stated his breathing was much better and felt good but this was only temporary, the next day he went

back to having sob

he had a pneuomia (with the pseudomonas) or he was going to end up with a chronic pleural effusion

:treated with timentin and vanco iv for pnemonia and possible sternum infection, increased wbc, sternum oozing moderate amount of blood, patient remains afebrile.

:m.d tells patient his sternum is unstable/ broken and he has to go back to or to re-wire his sternum (so that's why the patient heard a clicking noise)

good reason to have the clicking noise.

here is my question:

his platlets are panic high, (499) increasing every day. won't you bleed out if your platlets are too high, being that he's going to or? i asked the nurse practioner and she said no. "if your plat count is high you are likely to clot, if your plat count is too low you are likely to bleed out.. is this true? now this is where i'm confused because when patient's have pacewires the doctor won't remove it if the inr is too high. they only remove it if the inr is less then 1.5.......she also said it is normal for his platlets to increase because he has a lung infection...is this true?

true. that is the characteristics of what the body does during an infection/septic state.

oh i forgot to mention this...bp 129/50 hr 59....gave 50mg of metropolo and 2.5mg of ramipril. asked nurse practioner and she said it was ok to give...4 hours later hr droped to 35-45, patient asymptomatic, md paged, i hooked up external pacemaker pads to patient just in case he went back down to 35bpm..

you did the right thing by questioning it, assessing the situation and coming up with a "just in case plan". probably would have staggered the anti-hypertensive doses...

[nursej22, MSN, RN]

I would suggest reviewing mechanisms of coagulation and hemostasis. There are at least 12 different clotting factors (including platelets and prothrombin) and any one of them can effect clotting. You probably administer heparin (thromboplastin), bivalrudin (thrombin), ASA and clopidigrel (platelets) so a good understanding of clotting mechanisms is valuable.

As for the metoprolol and ramipril, you didn't mention how low his BP went but if a pt is assymptomatic, I wouldn't have attached the pacer pads. The ramipril doesn't lower HR, and that is such a small dose, I doubt that it would lower the BP much.

I have never heard of a patient being able to hear a pacemaker--mechanical valves yes, but not pacers.

BTW some sternal clicks are benign.

[Virgo_RN, BSN, RN]

Hm, in the two years I've been a cardiac nurse, I have never heard a pacemaker click.

As far as platelets and INR, as mentioned by a previous poster, they are two different things. Platelets stick together to form clots, and INR is a measure of clotting time. The higher the INR, the longer it takes to clot.

As far as the bradycardia, I wouldn't freak out over a rate of 35 unless the patient is showing signs of poor perfusion such as changes in level of consciousness, hypotension, dizziness, etc. People on beta blockers frequently dip down into the high 30s when sleeping.