Cystoscopy and Warfarin

[DrAllan]

Jerry (aka computec)

I?m not sure how old this joke is.

The residents of Heaven are waiting on line at the Celestial cafeteria. Suddenly a tall imposing gentleman (I presume that today to be PC it should be ?person?) cuts into the head of the line, and is rapidly given a tray of food. He then proceeds to sit down at a table by himself.

One of the newly arrived asks an angle ahead of him, ?Who is that??

The angle replies, ?Oh, that?s God, every once in a while he likes to play Doctor?.

I was part-time medical director of a 250 bed hospital for 7 years. Doctors with big egos are dangerous. We all forget something at sometime. These characters do not take the hint when reminded, especially by a patient versus another doctor. My advice is to ask the nurse who hangs the IV pac what is in it. Do not take an answer that says, ?Oh, an antibiotic.? You will need to ask which one it is. If Gentamycin® or garamycin, then issue closed. If not, the question to ask is, ?What gram-negative organisms does it cover?? The answer that you want is, ? E coli, klebsiella, Proteus, and Pseudomonas?.

 

[Guest]

And if it is not gentamicin, it costs too much or else doesn't cover those organisms.

 

[Computec]

Thanks once again, Dr. Allan for the information and ammunition.

Ya know, I've heard that joke told a different way.

A doctor arrives at the Pearly Gates and sees the long line. He immediately cuts to the front of the line and introduces himself to Saint Peter as Dr. Smith. Saint Peter tells him to go to the back of the line and the dejected Dr. Smith complies. Some time passes and a gentleman carrying a doctors black bag rushes past and goes to the front of the line. Saint Peter immediately waves him in. Doctor Smith is mortified and once again cuts his way to the front of the line. He asks Saint Peter why the other doctor was allowed in while he, a well known surgeon, was sent to the rear of the line. Saint Peter immediately tells him "That gentleman was God pretending he's a doctor."

I'll be watching what the urologist and his assistant do on Friday (but not too closely !) If they use a different antibiotic or no IV at all before starting the procedure what do you suggest I do?

Thanks

Jerry

 

[Computec]

Oh, by the way...

Does the fact that I'm allergic to penicillin preclude the use of garamycin?

 

[Blanche]

Does your uruologist know that you are allergic?????

I'm not a medical doctor, but some really good advice for many situations might be, keep your clothes on until you know what is going to be done to you.... The time for questions is long before you enter the hospital/surgicenter.

By now you are aware of the proper procedures and proper medication needed for your procedure. You really do need to talk to your uruologist before the sun sets again...... Please don't take chances with endocarditis!!It's a nasty thing to have and it takes a whole chunk of time out of your life to say nothing of whatever residual physical and emotional effects remain
after it is gone. Take charge...

Blanche

 

[Computec]

One of the first things he asked me was if I was allergic to anything. Yes. He knows that I'm allergic to penicillin. Whether or not he acts upon that knowledge properly is another matter. I'll be checkin', for sure.

That's really the purpose of this thread, Blanche. I'll taking advantage of everyone else's experience and knowledge.

Cynicism, when applied to how others treat one's precious body, is a necessary trait in my opinion. We have to be proactive and our own advocate... not just with the medical community but the phone and electric companies as well.

 

[Guest]

Gentamicin has no cross-allergy with penicillin.

 

[catwoman]

And if it is not gentamicin, it costs too much or else doesn't cover those organisms.

Al:

Is gentamicin the same as gentacin (sp)? Just curious, because my vet has given me a vial of gentacin to use with lactated ringer's solution for nebulizing kittens/cats.

 

[Guest]

Probably. Gentamicin is the generic name and if Gentacin is the brand name then the generic name shouls be in type 1/2 the size of the brand name and directly after or below it. At the time that gentamicin was introduced there was a bunch of drugs with names ending in -mycin. Many people would say that they were allergic to "mycins" so in order to differentiate the generic name was spelled with an i instead of a y.

 

[DrAllan]

Several factors need to be considered. Firstly, the IV infusion should be completed 1 hour prior to the actual performance of the cystoscopy (plus minus a short period of time for set up.) In actuality the risk of septicemia begins at the moment that the local anesthetic agent is instilled into your urethra. \

The time course of infusing the drug should be between 30-60 minutes. Thus the IV needs to be started and the drug hung 60-90 minutes before the procedure. You can judge right now whether the time for arrival at the outpatient center and the time told to you for the procedure meet these criteria.

Now to answer your question about what to do if they don’t give IV antibiotic or a different one. Basically there are two possible scenarios. The least desirable one goes something like this; “Doctor Stupid, I seem to know a lot more about the risks of this procedure and my medical condition related to my mechanical heart valve than you do. If I get endocarditis from this procedure because you did not give me the appropriate prophylactic antibiotic, I or my estate are going to sue your butt for every cent you have.”

OR, more diplomatically. “Having a mechanical heart valve has been an eye opener for me into the complexity of medical therapy. I think that you and I need to work together to get the best results for my therapy. Even before my valve surgery, Dr.Nakamura and his staff impressed upon me the need for endocarditis prophylaxis. I have done a fair amount of research into the medical literature regarding this to become better informed. As I understand it, the relative risk and difference between oral bacteria and genitourinary tract bacteria is significant. I would like to receive an appropriate gram-negative coverage antibiotic such as garamycin and have my blood levels high at the time of the procedure.”

 

[Computec]

Dr. Allan...

You're a man after my own heart. I've contemplated all that you and the others have said, taking into account what the urologist relayed to me via his receptionist today, and I just think that cancelling the whole thing is a good idea.

I was told that the whole procedure would take approximately 20 to 30 minutes. That amount of time does NOT allow for sufficient time for the IV as you've described. I'll call his office tomorrow and insist on the 1 to 1 1/2 hour preprocedure IV with the gram negative Gentamycin® or garamycin and if he balks at this it'll be "Bye Bye."

Time to find another urologist if I feel the need to pursue this procedure. As others on this forum have said (and other sources on the internet have verified) microhemoturia is not uncommon with warfarin therapy. If this particular urologist intends to jepardize my health with improper procedure it's time to call it off.

And, yes. Doctor Nakamura gave me a list of procedures requiring prophylactic premedication. One of those listed is cystoscopy. The only thing he didn't mention was how I should expect the prophylactic to be administered and when to head for the door if it wasn't developing as it should.

I definitely do not want a cavalier attitude from my medical practitioners. An over-the-counter test is available and, as Marsha said, the hematuria comes and goes with we eaters of rat poison.

Thank you and others for your responses.

Jerry

 

[Ross]

Jerry 20 to 30 minutes sounds like a long time. Just so you know, mine was in and out in just less then 15 minutes. Yes I know that doesn't allow time for the IV, but the procedure itself is not long at all.

 

[catwoman]

Jerry:

Check out:
http://www.bms.com/cgi-bin/anybin.pl?sql=select PPI from TB_PRODUCT_PPI where PPI_SEQ=91&key=PPI

The prescribing leaflet that comes with Coumadin says that hematuria is a sign of overdosage. However -- who's to say what's an overdosage? One person's range is 2.0-3.0; another's is 3.0-4.0, based on perhaps multiple valves & stroke. To get to 3.0-4.0, you need more warfarin/Coumadin than the first person. I would think you'd run a higher risk of having microscopic hematuria.

 

[DrAllan]

This thread is getting out of hand. Ross brings up an interesting point as to timing. As a group, surgeons usually only count the time that they are involved doing a procedure. They forget or discount the preparation time and the clean up time. So 20-30 minutes does not include all of the ?foreplay?.

A more important point is exactly what does microscopic hematuria mean. One must start from the basic assumption that normal tissue does not bleed. When it is damaged or inflamed then bleeding can occur spontaneously. The normal lining of the bladder does not bleed easily. Thus, any bleeding needs to be taking as a sign of possible tumor until it is ruled out. What would be brief minor oozing, and probably undetected, in a patient not on Coumadin turns into a major affair in those on the drug. Again, in most cases this becomes an annoyance, on the other hand you might be getting an early warning of something more serious.

Let us assume that your cystocopy is normal and that no obvious focus of bleeding is found. What does your urologist suggest to you if you continue to have brief episodes of recurrence? Are you committed to annual cystocopy because of this? I myself am faced with this same problem, although my bleeding is probably from kidney stones that are in place. So those on this board who are following this thread need to be cognizant of the uncertainties of medicine and decision making.

 

[catwoman]

Dr. Allan:

When in doubt, check it out. (my philosophy)

I've had slight UTI from time to time, with microscopic hematuria. This has gone on for years and has not just been since going on warfarin. I've been tested in the past, nothing found.

One question:
Does hematuria always mean the blood is coming only from the bladder, or is it microscopic blood cells being filtered through the kidneys and going to the bladder?

 

[Computec]

Marsha, Ross and Dr. Allan...

It was my intention to query the urologist today regarding the IV of gram negative antibiotic but he was on shortened hours and this was impossible.

When I reach him tomorrow I will tactfully ask how long the ENTIRE procedure (including foreplay) will take, including the administering of the antibiotic. This should give enough information to enable me to decide if he and his staff understand the danger of endocarditis.

I greatly appreciate the experiences and knowledge shared by all of you. It allows me to be a better advocate of my own best interests in all of this.

Thanks

Jerry

 

[DrAllan]

Marsha,

Heamaturia comes from the Latin, Hema blood and -uria urine. Stricctly speaking it really refers to red blood cells rather than any orther component of blood suvh as white blood cells.

 

[Computec]

Levaquin

Levaquin

I took the liberty of stopping in to see my urologist prior to tomorrow's procedure to get answers to the prophylactic question. I tend to have better luck in face to face meetings.

He assured me that, although he would not be administering garamicin via an IV prior to the procedure, he provides Levaquin, usually after the procedure. Hmmmm.

I told him that if it is equivilent in it's gram negative capabilities it would be fine. However, taking into account that the prophyactic is more effective when taken prior to a procedure he handed me a 500 mg tab of it and said to take it with food 1 hour prior to my appointment.

My online research indicates that it's effective against the organisms that you mentioned, Dr. Allan.

Sounds like headway

Jerry

 

[Computec]

Further research shows that Levaquin is not a "bacterocidal" as garamicin is but interferes with the reproduction of the bacteria (bacterostatic). I believe that Levaquin is the prophyactic given to all patients undergoing a cystoscopy since the incidence of post-flexible cystoscopy infection, without benefit of prophyactic antibiotics, is 21% across the board. This drops to 5% with garamicin. I wonder what it drops to with Levaquin.

Sounds like the best I can do with my urologist is getting him to provide Levaquin in advance. He probably feels that the additional time and cost of a decent IV prophyactic for high risk patients isn't worth the effort considering the odds.

Hey. What's the worst that can happen? I die and my family wins a big lawsuit. There are better ways to earn money.

 

[DrAllan]

I am not impressed with your doctors concern re a mechanical heart valve. There are no studies showing its rate of effectiveness in prophylaxis. This is not to be taken as a criticism. The market for the use of this drug is small and there is little incentive for a drug company to spend millions to get FDA approval for this indication. Likewise there is probably not much funding for an independent investigation. In spite of this, I’m sure there are many times the drug is so used. Logically, the drug is effective against gram-negative organisms although static not cidal. The drug is usually given 1 hour before a meal or two hours after a meal. This is so that the stomach is essentially empty to allow for good absorption. There are changes in ‘QT’ interval inpatients on amiodarone or sotalol.

Allow my medical cynicism to come into play. You wrote, “Sounds like the best I can do with my urologist is getting him to provide Levaquin in advance. He probably feels that the additional time and cost of a decent IV prophylactic for high risk patients isn't worth the effort considering the odds.” I wonder if this procedure is being done in the doctor’s office where he has no access to giving an IV. If this is the case then he would have to use an outpatient facility, either free standing or hospital based. This costs him TIME in getting there and back to the moneymaking office. The cost of the sample of Levaqin he gave to you is nothing. The cost of the garamycin, IV tubing, bottle of saline, and needle is probably around $30.00. The CHARGE to your insurance might be $150.00. Finally, taking Levaquin after the procedure is not prophylactic. Once the scope is withdrawn, you are not likely to be seeding the blood stream with bacteria. The amount of time for the oral medication to achieve high concentrations in the blood to “kill” bacteria will exceed the time for bacteria to find and settle on your valve.

Bottom line, probably taking oral Levaquin pre-op will be almost as effective as IV garamycin. As I said above, I’m not impressed with this doctor’s analysis of your cardiac condition.

This answer is not intended as and does not substitute for medical advice - the information presented is for patient education only. Please see your personal physician for further evaluation of your individual case.