$19 million judgment highlights need to monitor for post-op complications

Here’s how to identify problems after laparoscopic cases

An Illinois woman recently was awarded $19 million after her bladder was punctured during surgery to remove an ovarian cyst and went undiagnosed for nearly two days, according to a news report.1 She subsequently suffered a stroke, necrotizing fasciitis (a flesh-eating infection), and amputation of some fingers and toes, the report said.

After the stroke, the patient was given medication to increase her blood pressure, the report said. A side effect of the medication reduced the flow of blood to her extremities, which led to the amputations, the report said. She underwent nine surgical procedures in two weeks, it said.

The inadvertent puncturing of her bladder was not a violation of medical care standards, the patient’s lawyer maintained. However, failing to see it, during the operation and later when the patient complained of pain, was negligent, he said in the news report. The patient reported intense pain in her abdomen the day after surgery. She was advised to take medication, but when the pain intensified, she went to the emergency department, her lawyer said. The severity of her condition was not recognized, he added.

The following morning, her husband walked into her hospital room and found her motionless after a stroke. Tests later showed that it was caused by urine leaking from the bladder, the report said. That led to an infection, decreased blood pressure, and other complications, her lawyer related.

To avoid similar problems in your program, consider these suggestions:

Look for signs of puncture in the OR.

If an organ is punctured in the OR, you may see bleeding or some leak of the enteric contents, which may show up as murky irrigation fluid, says Paula R. Graling, RN, MSN, CNS, CNOR, clinical nurse specialist in perioperative services at Inova Fairfax Hospital in Falls Church, VA.

"If you puncture into a vessel, you may have frank bleeding and problems with blood pressure," Graling says.

Although such complications are rare, they should be discussed initially when the patient is trying to decide whether to have a laparoscopic procedure, she emphasizes.

Be alert for excessive pain in the recovery room.

Keep alert for unstable vital signs, continued restlessness, excessive pain, and distention of the patient’s abdomen in the recovery room, sources advise.

"The caveat is that the patient has been inflated with CO2, so that gives you pain, particularly in the shoulder," Graling says.

One way to know there’s a complication is when the patient has pain that’s unrelieved with normal pain medication, she says.

Send patients home with written postoperative instructions.

It is essential that the recovery room nurses and any other nurses providing post-op instructions offer written instructions, says Wendy Winer, RN, BSN, CNOR, endoscopic surgery specialist at the Center for Women’s Care and Reproductive Surgery in Atlanta. "Always remember that whatever you tell patients or family members or whoever is with them, when they get home, they forget all of that," she says. "It’s imperative that they have something written to look at."

The key is that the written instructions including warning signs for complications, such as a temperature above 100.5° F, heavy bleeding, severe pain, difficulty urinating, and difficulty having a bowel movement, Winer says. If patients experience any of these problems, they should contact their provider immediately, she adds. Phone numbers should be provided that allow contact 24 hours a day, seven days a week, Winer says.

Have the physician and facility make postoperative calls.

In the surgeries that Winer participates in, the patients receives a post-op call the first day home from the physician’s staff and the facility staff.

"It’s not absolutely imperative that you have both, but it’s good continuity of care," she says. "In this day and age, when patients are going home so quickly, we really have to be careful, extra careful, of the potential of post-op complications being undiagnosed." The sooner complications are identified, the more quickly they can be addressed, Winer points out.

Keep an eye on symptoms of complications.

When urine leaks into the abdomen, it can cause symptoms of irritation, such as a low-grade fever, pain, and sometimes nausea and vomiting, says William Parker, MD, clinical professor of obstetrics and gynecology and the University of California, Los Angeles School of Medicine and author of A Gynecologists’ Second Opinion (Penguin Plume, New York City).

When you operate in the abdominal cavity or pelvis, look for any signs of perforation of the bowel, any signs of injury to the ureter, a hole in the bladder, any signs of bleeding, or any signs of post-op infection, Winer advises. Determine if patients are having any trouble voiding, she says.

Look for patients to improve.

One rule about laparoscopic surgery is that patients should get better every day after the first 24 hours, Winer says. Parker adds, "If they’re not getting better, a problem should be looked for."

Complications can be difficult to pinpoint, Winer acknowledges. "The patient may just not be feeling great and may not be getting better," she says. Also be alert if a patients feels fairly good initially, but starts to worsen a couple of days later and continues to feel bad. "That always sends up a red flag that something’s going on," Winer says.

Ensure patients don’t overmedicate with pain drugs.

If patients are uncomfortable the first or second post-op day, they have a tendency to take more pain medicine, Winer says. "I think you have to be careful with that, because a lot of times, even taking pain medicine can cause other side effects," she says. For example, patients can become severely constipated or nauseated, she says. "At the same time, taking too much pain medicine post-op can camouflage a more serious problem that would imply something more than normal post-op pain," Winer warns.

Have the physician examine patients with significant degree of pain.

While some patients feel fairly good the day after surgery, others feel sore for a couple of days, Winer says. "The trick is to differentiate between what’s normal post-op discomfort and when something really going on," she says. "For that reason, it’s important, in my opinion, that whenever a patient complains of significant post-op discomfort the first post-op day, you take every complaint seriously."

If the patient is having a significant degree of pain, the physician should examine the patient, Parker says. The determination is difficult to make over the phone, he acknowledges. "If patient is saying, Oh, I’m having some cramping, but it goes away when I take pain medication,’ that’s one thing," Parker says. "But if the patient is saying, I can’t keep pain medication down; the pain is getting worse,’ I think they should be examined. That’s the thing to do."

Physicians can get into the mindset that if they didn’t note any complications during the surgery, there weren’t any, he says. "I think sometimes doctors put their heads a bit in the sand," Parker says. "When a patient does start to complain, they miss the fact that complications can occur. They should be looking for that."

Reference

1. Ciokajlo M. Injured woman gets $19 million — Surgical error led to loss of digits, stroke, infection. Chicago Tribune, Oct. 2, 2003. Web: www.chicagotribune.com.

Sources

For more information on diagnosing punctured organs, contact:

  • William Parker, MD, 1450 10th St., Santa Monica, CA 90401. Telephone: (310) 451-8144. Fax: (310) 451-3414.
  • Wendy Winer, RN, BSN, CNOR, Endoscopic Surgery Specialist, Center for Women’s Care and Reproductive Surgery, Atlanta. E-mail: wwiner@mindspring.com.