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General / local anesthetic for bladder biopsy - low heart rate


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My question relates to low heart rate and operation under general / local anesthetic.

 

Hospitals in Khon Kaen.

Hospital # 1 – January – Cataract op –

Visit # 1 – Past medical history / allergies etc., general body check BP and heart rate etc.   Asked if I preferred local or general anesthetic, opted for general.  ( NB they mentioned nothing about my low heart being a possible problem for general anesthetic ).

Visit # 2 – Usual body check etc., doctor commented on my BP and heart rate again BP high ( 160 – 170 ) and heart rate low ( 37 – 42/5 ), same as first visit.   ( Have been on single med max dose for BP for years ).

I again mentioned to doctor that I had a low pain threshold, doctor said can operate using local anesthetic and if BP spikes during op, which it did, they can / did give an injection that brought my BP down very quickly.

 

 

Hospital # 2 –

Last month ( August visit #1 ) diagnosed with probable bladder cancer following passing of blood clot in urine and ultrasound scan.

Past medical history / allergies etc., general body check BP and heart rate etc.  General comments only on my low heart rate.

Asked if I preferred local or general anesthetic for biopsy and removal of tumor, opted for general due to my low pain threshold.  ( NB they mentioned nothing about my low heart being a possible problem for general anesthetic ).

This month ( Sept visit #2 ) for general chat about options and risks.   I decided on general anesthetic.    No mention by hospital that they could not operate due to my low heart rate.

Please come again tomorrow and we will do biopsy, you will need to stay for a few nights.

Arrive next day at hospital with “overnight” bag.  

Talked with doctor and hospital anesthetist “Oh, we cannot operate because your heart rate is too low.    You need to discuss with specialist anesthetist at KKU.

 

Following Day -

KKU – Cardiogram test - you have a heart blockage and cannot operate unless your heart rate is 50+.     Your HBP is also a risk ( no mention of injection to bring it down during op ).

You first need to have a pacemaker fitted. There was no mention about having a heart pacemaker installed whilst I still had a low heart rate.

 
The head anesthetist said that if I sign to agree to take responsibility for any complications during biopsy and tumor removal under general anesthetic then the operation can be carried out at second hospital.   A letter was produced to that affect and signed by me.

 

My questions are:-

“Why did the first hospital NOT mention that the eye operation could not be carried out under general anesthetic ( had I requested it ) ?

“Why did the second hospital not mention that the biopsy could not be carried out under general anesthetic until I arrived ready for the operation ?”   

“Why did KKU not mention about how they would fit a pacemaker whilst my heart rate was low ?

 

At the moment I am in a Catch22 situation. I am 74. I cannot do either the heart op nor the biopsy.     For me the biopsy is the most important as it is a “Now” thing, the low heart rate I have had for many years and it has, as yet, caused no problems, I exercise, walking and yoga, do not get out of breath, not weak etc.    I did have a stroke complicated by rhabdomyolysis which caused acute renal failure, I improved rapidly, meaning I did not do dialysis, started walking and was fitter than ever within 3 months.  I can look at alternative ways to limit cancer spread if the biopsy is positive.    I do not smoke or drink.


What should I do ?    Is it worth going back to the First hospital ( cataract ) who can do the bladder biopsy, ( they use the same surgeon as the Second hospital ) ?    Providing of course that they accept the KKU letter, which is what they requested me to get.    Of course even if one goes on consecutive days they charge to tell you what you weigh and show you that you are still the same height.

Anyone else been in similar situation ?  can PM me.   Will name hospitals if requested.

Would be grateful for any suggestions.

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The issue of the low HR was given attention only when you met with the actual anesthetist, which it sounds like you did not  do at Hospital #1 since you ultimately had a local?

 

Medical care in Thailand is extremely specialized and Thai doctors have less all round knowledge (knowledge outside their area of specialization) than their counterparts in other countries. 

 

Certainly if your BP shoots up during surgery it will be dealt with, whether mentioned in advance or not.

 

I don't understand "Why did KKU not mention about how they would fit a pacemaker whilst my heart rate was low ? " as it sounds like they did mention installing a pacemaker. (also you should refrain from thinking of actions or statements as having been done by the hospital, they were done by specific doctor and a different doctor in the same hospital might well have done differently).

 

I also do not understand your statement that you cannot undergo "the heart op". Are you referring to pacemaker insertion? Why would you be unable to undergo that?

 

I assume by "heart blockage" you do not mean coronary artery disease but rather Heart Block which is a disturbance of electrical conduction in the heart. Did they specify what type (First Degree, Second degree etc)?

 

If you are in HB, it would indeed be very, very dangerous to do surgery without a pacemaker and indeed, it is dangerous even without surgery.   Depending on the type of  HB, it  is the most pressing health problem at this time . Just because you have had a slow heart rate for some time does not change this, it is a progressive condition.

 

At any point in  these consultations did you see a cardiologist? And what medication are you on for your BP? I ask because if on a beta blocker, these have the effect of slowing the hear rate and can in themselves cause First Degree HB. If you are on a beta blocker and it is 1st degree HB,  it is possible that a change of medication could resolve it.

 

Your immediate priority should be to see a good cardiologist to get to the bottom of it and treat the HB, whether just by changing medication or by inserting a pacemaker. In either case should be able to get things straightened out within 1-2  weeks and that much delay in the biopsy will nto substantially affect your prognosis. Once that is done and a cardiologist agrees you can undergo surgery, can then proceed.

 

I recommend you go through the after hours clinic at KKU and try to see Prof. Pattarapong Makarawate there. As soon as possible.

 

Do not focus just on having the biopsy. Even if that goes OK, if it is positive then more extensive surgery comes next. You need to deal with the cardiac issue first (and promptly). 

 

 

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I cannot see how you can have local anaesthetic for removal of that bladder tumour.

I had bladder cancer at 42 and whilst the cystoscope (sp) was shoved up on initially investigation (and if you havent witnessed or been on the end of that scenario its not amusing) but I was told subsequently that what they shove up the penis for the actual tumour removal is monstrous in size and would frighten an elephant

 

As such I cant imagine a local anaesthetic

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In theory you could do a spinal block and be numbed from the waist down, but in this case unlikely since he has a low heart rate that has been investigated.

 

The other option is a penile block (regional anaesthesia) that would numb the whole penis.

 

Neither would require the patient to be asleep (general anaesthesia - which anaethetists don't like to perform when you have certain pre-exisiting cardiac or non cardiac conditions)

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