some bubblic!
In reviewing the literature for this chapter, I was surprised to find that so many people have pulmonary emboli and that a large proportion of them die of the disease. When a large clot breaks loose in a vein and travels through the venous system to the heart and through the right side of the heart into the lungs, death may be instantaneous when the body is unable to get oxygen. There are other factors involved that we don't need to consider, but it's important to note that almost 50% of patients dying in the hospital have some degree of pulmonary emboli. If the diagnosis is made, then ninety percent will survive; if the diagnosis is not made, only seventy percent will survive, so it is important to know the signs and symptoms and be sure that your physician knows about them and starts appropriate therapy rapidly.
But let's go back a few steps. Who develops these blood clots, and why do they develop? Normally, blood flows continuously from the legs into the large vein in the abdomen and chest, the vena cava. But under certain circumstances, blood flow is diminished and sets up a background for co-agulation or clotting to occur. As long ago as the 1880s the famous German physician Rudolf Virchow determined that three factors were responsible, for the occurrence of blood clots or thrombosis. They are known today as Virchow's triad and consist of (1) stasis or slowing down of blood flow in the vein, (2) injury to the vein, and (3) an increased tendency for the blood to clot, called hypercoagulability.
The causes of this triad are many, but the main ones that concern us here are those related to surgery. When a patient has an operation, he often is lying down for a prolonged period with no muscle activity; the patient is often paralyzed by the anesthesiologist so that the surgeon can operate in a motionless field. This operative inactivity and the postoperative bed rest are highly conducive to stasis in the veins, and thrombosis or formation of clots can occur more readily. This problem may be more common as we get older, and it takes longer to recover and ambulate.
When a patient gets dehydrated or if there is a decrease in blood thinning factors, then there will be an increased tendency for clots in the vein. Because of the increased pressure in arteries, blood clots are less common, and any clots that occur don't ever go to the lung—it's the wrong direction; as you recall, arteries take blood away from the lungs and heart to the tissue; veins take blood from the tissue to the heart and lungs!
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
