Here is another patient of mine who would benefit from intercontinental consultation:
63 year old male had Millin's prostatectomy under spinal anaesthesia three days back. He has history of bronchial asthma. We routinely put the pts on saline irrigation of the bladder using a trichannel Foley's till the wash comes out clear. This takes about 48-72 hrs. Sometime when there is little too much blood in the wash immediately after the operation, mild traction is put on the Foley's to cause pressure on the prostatic bed by the balloon. This is kept for about 6 hrs and does the trick very well. I haven't faced any problem with this procedure. In this pt the traction is overlooked for 24 hrs.
He has a blocked Foley's on 3rd PO late at night (2 am). the irrigation continues for about 3 hrs before the blocked Foley's is discovered. The intern tries to reopen the block by pushing in more saline. The pt becomes restless and abdomen starts to swell. I am informed at 7 am. I find the pt very restless, abdomen distended, not tender, silent, no vomiting, pt in shock. I suspect :
1. Clot retention in bladder.
2. One way irrigation cause increase pressure and leak in the prostatic capsular repair.
3. Saline and blood enters the retroperitoneal space (Extra peritoneal rupture of bladder !)
4. This causes paralytic ileus. Distension causes ACS.
We stop oral feeding, put a nasogastric tube, start IV fluid. Distension continues to increase. I take the pt to OR as soon as the vital signs stabilizes. This time under GA I explore the bladder, remove about 200 cc old clot, change the Foley's, put a supra pubic Malecot catheter. Just before closing the bladder I discover a small rounded hole in the post wall of the bladder with congested surrounding mucosa. I repair the hole before closing the bladder. I tried to aspirate any fluid in the area outside the bladder, there was not much. Clear fluid was oozing out from somewhere while I was closing the wound. Kept a retro pubic space drain. Unfortunately pt has a cardiac arrest on way to the recovery. He was resuscitated by CPR and was put on ventilators. He is still unconscious (after 24 hrs), laboured breathing, pupils reacting to light, no other obvious focal neurological signs. Abdomen has become completely soft in 6 hrs.
Any thoughts on:
1. What caused the mishap ?
2. What next ?