Cardiac Stent + Elective Case

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RxBoy

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Hypothetical Scenario:

Pt comes for a elective TKA. Pt had 2 DES placed in LAD and Cx 3 months prior. Pt comes in for elective surgery. Seen by his cardiologist and states pt can proceed for surgery from cardiac standpoint and stop taking plavix 7 days prior. Advises to continue taking 325 mg aspirin prior to surgery and stop plavix 7 days prior. See pt for first time in preop. Tell him there is a high likelihood of stent thrombosis with subsequent MI possible death. Pt states willing to take any chance to just fix his aching knee. Surgeon wants to proceed.

ACC/AHA guidelines says 12 months, cardiologist says 3 months is fine.
What would you do?

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BTW

Revised 2014 summary of ACC/AHA guidelines:

"According to the guideline, elective noncardiac surgery should be delayed 14 days after balloon angioplasty, 30 days after bare-metal stent implantation, and optimally 365 days after drug-eluting stent implantation, although the data in this area are evolving. This has resulted in a new class IIb recommendation acknowledging that elective surgery more than180 days after drug-eluting stent implementation may be considered if the risks of waiting outweigh the risks of the patient sustaining a cardiac event. Coronary artery bypass graft surgery should only be performed if it would be indicated independent of the noncardiac surgery."
 
I don't see how the benefits outweigh the risks here. If it was a BKA for osteo, gangrene, etc., then sure. Prop, sux, tube. Is he completely disabled by pain, unable to work and/or wheelchair bound?
Perhaps all of his heirs can sign a release of liability drafted by the hospital attorney.
I don't understand why the surgeon would push for this or why the cardiologist doesn't think they need to follow the recommendations.
Schedule him in 3 more months, unless there is some compelling need to proceed.
 
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Postpone surgery for 9 months or find a different anesthesiologist.

The cardiologist does not clear the patient for surgery. I clear the patient for surgery. All the cardiologist can do is tell me his opinion about how optimized this patient is.

In American malpractice courts, patients are treated like innocent children, and doctors like sleazy candy salesmen. Juries have difficulty accepting bad outcomes, even if discussed during consent. Especially if the patient dies, it will come down to "you should have known better, doctor".

I will do a cataract 6 months after a DES, but not a TKA.
 
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Isn't the risk of stent thrombosis related to stopping Plavix? If he's been off it for 7 days, does the risk increase even more intra-operatively?
 
Isn't the risk of stent thrombosis related to stopping Plavix? If he's been off it for 7 days, does the risk increase even more intra-operatively?

Yes. Stress of surgery and post operative stress/pain put these patients at high thrombosis risk. Higher than not having the surgery. These patients are already at a large risk for DVTs, thats why they are put on anticoagulants so early post op.

I had a similar scenario couple weeks ago. The private attending in me had an itch to just do the case, but ultimately I decided to postpone the case for at least 6 months post stent placement. Needless to say, surgeon and patient were not happy.
 
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Isn't the risk of stent thrombosis related to stopping Plavix? If he's been off it for 7 days, does the risk increase even more intra-operatively?
Even if it didn't increase intra-operatively (which it does), there might already be a nice little thrombus there (one week off Plavix), waiting to become a heart attack under your watch.

That's why I said that I was fine with doing a cataract (which does not require stopping Plavix) at 6 months.
 
"Private attending itch to do the case" is not equal to sloppy medicine, or at least it shouldnt be. Private attending itches should be just as sound clinically as academic attending itches, if not more so.
As a private attending you lack the big name to back you up for making stupid choices. It is gonna be a tough sell getting a jury to think that the expert at Harvard wasnt perfect, but that idiot at the shop down the street who did the exact same thing is far more likely to be crucified. That cardiologist may not testify that the guidelines say to wait, but you can bet that a lot of his friends would.
 
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I am considered something of a cowboy. I push the line on doing cases just about as far as it can be reasonably pushed.

And there is abso****inglutely no way in hell I do this elective case with a 3 month old DES in the LAD.

I also might report the cardiologist to the medical board.

Edit: I see you say this is a hypothetical scenario. I sure hope so.
 
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Delay 9 months, call cardiologist - tell him you just saved him from being sued and your fee is 10% of what the settlement would have been.
 
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Edit: I see you say this is a hypothetical scenario. I sure hope so.

Believe it or not, a situation like this has happened 3 times in my career. Obviously the scenario I gave had completely different details. But its essentially a push/pull between cardiology and anesthesiology. Surgeons will immediately side with cardiology even though as an anesthesiologist, we have the ultimate say. Cardiologist can only make a risk assessment, its OUR job to determine if that risk is worth it.

And I agree, even if cardiology has a note stating the patient is cardiac "cleared" for surgery, that still doesn't protect you.
 
Scenario #2:

Pt on ASA/plavix not discovered still on ASA/plavix until day of surgery, Surgeon finds out and still wants to do an elective surgery even though the surgery has higher risk of bleeding (total joint/open GI/ect). Assume the Hgb is stable and the pt could stop the ASA/plavix.

Do you proceed?
 
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it's easy. I call the cardiologist. Ask what they are thinking. Ask why they stopped plavix and ask why they think elective surgery is such a good idea at this time. I'll let them know I just want to document our discussion and their reasoning. Then I'll talk to the patient.

99/100 at that point the patient and/or cardiologist are asking me not to proceed (and I'm not the bad guy). That's your PP answer. In academics, people cancel the case and both the patient and surgeon hate them. In PP, the case ends up being cancelled, but not by me and everybody still likes me.
 
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The private attending in me had an itch to just do the case, but ultimately I decided to postpone the case for at least 6 months post stent placement. Needless to say, surgeon and patient were not happy.

Just curious, what did the surgeon have to say after you canceled their case? Did you face any backlash or repercussions for doing so? Did the surgeon just find another anesthesiologist to do it?
 
Just curious, what did the surgeon have to say after you canceled their case? Did you face any backlash or repercussions for doing so? Did the surgeon just find another anesthesiologist to do it?

He was upset but understood my rational. Usually its not a big deal but the patient was really really upset. Usually you can scare the patient into avoiding the procedure, but this particular patient was so adamant of getting his procedure. He was especially upset because he has to pay the new deductible. All the talk of heart attack and death didn't dissuade him. I had the cardiologist, surgeon, and patient against me. Just had to suck it up and be the bad guy.

No backlash or repercussions, my partners would of done the same thing.

Plus any anesthesiologist knows that agreeing to do a case when another anesthesiologist refused would make a malpractice lawyer salivate.
 
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He was upset but understood my rational. Usually its not a big deal but the patient was really really upset. Usually you can scare the patient into avoiding the procedure, but this particular patient was so adamant of getting his procedure. He was especially upset because he has to pay the new deductible. All the talk of heart attack and death didn't dissuade him. I had the cardiologist, surgeon, and patient against me. Just had to suck it up and be the bad guy.

No backlash or repercussions, my partners would of done the same thing.

Plus any anesthesiologist knows that agreeing to do a case when another anesthesiologist refused would make a malpractice lawyer salivate.

It's great to hear that you had the courage to stand your ground against all three. :thumbup:
 
If after explaining to the patient the risks and the concerns you have the patient still insists on proceeding with the surgery, and assuming the patient is a mentally competent adult, you should document your discussion with the patient and proceed with the surgery.
 
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Scenario #2:

Pt on ASA/plavix not discovered still on ASA/plavix until day of surgery, Surgeon finds out and still wants to do an elective surgery even though the surgery has higher risk of bleeding (total joint/open GI/ect). Assume the Hgb is stable and the pt could stop the ASA/plavix.

Do you proceed?
The bleeding risk here is mainly a surgical concern and if the surgeon is fully aware of the increased risk and the patient had a full disclosure of the risks, and they both want to proceed then you should proceed.
 
No backlash or repercussions, my partners would of done the same thing.
That's what matters the most. IMO, one of the criteria for a bad group is when your partners/boss don't stand with your decisions, even if they disagree (but that's the group's dirty laundry, not a matter of public machoism - I am the boss, let me show you how this case is done and/or that the surgeon is more important than you or your concerns).
 
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Hypothetical Scenario:

Pt comes for a elective TKA. Pt had 2 DES placed in LAD and Cx 3 months prior. Pt comes in for elective surgery. Seen by his cardiologist and states pt can proceed for surgery from cardiac standpoint and stop taking plavix 7 days prior. Advises to continue taking 325 mg aspirin prior to surgery and stop plavix 7 days prior. See pt for first time in preop. Tell him there is a high likelihood of stent thrombosis with subsequent MI possible death. Pt states willing to take any chance to just fix his aching knee. Surgeon wants to proceed.

ACC/AHA guidelines says 12 months, cardiologist says 3 months is fine.
What would you do?


We agree here. Waiting another 3 months before proceeding with the elective TKA. 6 months post DES and Cardiology "clearance" is good enough for me.
 
Elective noncardiac surgery in stented patients — In order to minimize adverse cardiovascular events, we suggest that elective noncardiac surgery be deferred until after the minimal recommended duration of DAPT for each type of stent. For patients treated with either BMS or DES who are not at high risk of bleeding, we suggest one year of DAPT. In patients at high risk of bleeding, our recommended duration of therapy is one and six months, respectively. (See "Antiplatelet therapy after coronary artery stenting", section on 'Noncardiac surgery or GI endoscopy'.)

While the optimal duration of DAPT for stented patients is not known, we are concerned that the proinflammatory and prothrombotic risks of surgery may increase the baseline risk of stent thrombosis even in the presence of DAPT if a significant percent of struts are not endothelialized. In addition, one cannot predict the possibility that DAPT might have to be stopped due to unexpected major bleeding. Thus, we recommend caution in performing elective noncardiac surgery prior to the minimal recommended duration of such therapy. Although the minimal duration of such therapy is four weeks for BMS, we recommend waiting six weeks given our concerns about the possible increased risk of stent thrombosis in the perioperative period.

The final decision to continue or discontinue antiplatelet therapy in the perioperative period should be made only after an informed discussion among the surgeon, managing cardiologist (and other health care providers), and the patient has taken place. Some surgeons are not fully aware of the risk of prematurely discontinuing antiplatelet therapy in patients with recent PCI with stenting. In many cases, DAPT can be continued in the perioperative period, although for some surgeries such as neurosurgery, posterior eye surgery, or prostatic surgery, the risk of major bleeding may be greater than the risk of stent thrombosis.

Our recommendations for the timing of surgery are based on observations presented above regarding the rates of stent thrombosis in patients with premature cessation of DAPT and rates of adverse cardiovascular events found in studies of patients undergoing noncardiac surgery. (See 'Timing, incidence, and clinical predictors' above.) No randomized trials comparing different times for surgery after PCI or differing antiplatelet strategies have been performed. These recommendations attempt to take into account what is known about the risk of perioperative bleeding on one or two antiplatelet agents.

If surgery must be performed before the minimum time period for DAPT (generally one year in patients not at high bleeding risk), we suggest that an attempt be made to defer it for at least six weeks after placement of a BMS and at least six months after a DES. In these patients, a platelet P2Y12 receptor blocker should be discontinued for as brief a period as possible. Aspirin should be continued through the perioperative period, since the risk of stent thrombosis is further increased with the cessation of both aspirin and clopidogrel and surgery can usually be safely performed on aspirin. (See "Perioperative medication management", section on 'Aspirin'.)

Additional points to consider include:

●Minor surgical and dental procedures usually do not require cessation of antiplatelet therapy



Clopidogrel, prasugrel, and ticagrelor should be stopped five, seven, and three to five days, respectively, before surgery. Some experts are willing to recommend shorter discontinuation periods, for procedures less likely to be associated with major bleeding.



Clopidogrel, if stopped, should be restarted with a loading dose of 300 mg as soon as possible after surgery, perhaps even later in the day if postoperative bleeding has stopped. Some experts recommend a higher loading dose of 600 mg to decrease time to effectiveness in the higher-risk postoperative setting [26].



●We suggest that surgery be performed in centers with 24-hour interventional cardiology coverage [26]. (See "Management of cardiac risk for noncardiac surgery", section on 'Revascularization before surgery'.)



Urgent or emergent noncardiac surgery — For patients who require surgery prior to the minimal duration of DAPT discussed above, such as those who require urgent or emergent noncardiac surgery, two issues need to be discussed among all managing practitioners:

●The relative risks and benefits of continuing DAPT



●Role of platelet transfusion. For patients who are at increased risk of bleeding, there will not be time to discontinue one or both antiplatelet agents. While platelet transfusion may be necessary for excessive bleeding after surgery, the role of prophylactic platelet transfusion has not been well studied. (See "Congenital and acquired disorders of platelet function", section on 'Platelet transfusion'.)
 
Revision guidelines on surgery after stent implantation needed
22-10-2013 • HAWN ET AL., JAMA OCT 2013

Risk of major adverse cardiac events following noncardiac surgery in patients with coronary stents.


Hawn MT, Graham LA, Richman JS et al.
JAMA. 2013 Oct 9;310(14):1462-72. doi: 10.1001/jama.2013.278787
Background
Because noncardiac surgery soon after coronary stent placement is associated with an increased risk of adverse cardiac events, it is desirable to delay elective surgery as long as possible after stent placement.
Guidelines issued by the American Heart Association (AHA)/American College of Cardiology (ACC) in 2007 have been revised after observations of unanticipated late stent thrombosis after cessation of dual antiplatelet therapy (APT) and case reports of stent thrombosis in patients with drug-eluting stents (DES) undergoing noncardiac surgery. The new guidelines recommend continuing dual APT for all patients at least 1 year after DES implantation [1]. If delaying surgery is not possible, it should be performed without cessation of APT.
However, the recommended delays are based on limited and conflicting evidence. Larger, multicenter cohort studies did not confirm the higher rates of major adverse cardiac events (MACE) seen in initial case series after DES implementation, as compared to bare metal stents (BMS) [2-4]. This study aimed to better understand the relationship between stent type, APT, and MACE associated with noncardiac surgery after coronary stent placement. A national cohort of Veterans Affairs (VA) patients who had either coronary DES or BMS placed were evaluated.
Main results
  • In a model assessing the relative contribution of factors to MACE, nonelective presentation for the surgical hospitalisation, conditions associated with ischemic cardiac disease and higher revised cardiac risk index (rCRI) score were significantly associated with MACE. Stent type was not associated with MACE, neither was there an interaction between stent type and time to surgery.
  • MACE was correlated to time from stent to surgery, with higher MACE rates seen for surgery closer to stent implantation. After adjustment, the odds of MACE for surgery between 6 weeks and 6 months after DES placement was lower than after BMS placement (adjusted OR (AOR): 0.75, 95%CI: 0.62-0.91). The odds were not different for surgery less than 6 weeks after stent implantation (AOR: 1.1, 95%CI: 0.8-1.5) or more than 6 months after stent placement (AOR: 0.92, 95%CI: 0.82-1.05).
  • No significant difference was observed in the likelihood of receiving dual APT prior to surgery (59.5% cases vs. 55.6% controls, P=0.43) or complete discontinuation of APT for at least 5 days (22.9% cases vs. 25.4% controls, P=0.49). There was no association between complete APT cessation and MACE (OR: 0.86, 95%CI: 0.57-1.29).
Conclusion
This study shows that the acuteness of clinical presentation for surgery and several markers of advanced cardiac disease is important for the development of MACE after noncardiac surgery in patients who recently had coronary stent implantation. Time from stent placement to surgery was associated with MACE, although only significantly in the first 6 months after the stent procedure. APT cessation was not associated with MACE.
Although future prospective studies should confirm the safety of noncardiac surgery at 6 months after DES implantation, these findings challenge the current focus on stent type and timing of surgery when assessing perioperative risk in patients with coronary stents. Additional cardiac risk factors appear more relevant in risk stratification in patients with stents.

Guidelines that recommend prolonged delay and continued APT for patients with DES need to be reconsidered.
 
Let me put it this way: if the cardiologist thinks the patient is not at risk for stent thrombosis after only 3 months of APT, that the stent has already endothelialized, why doesn't he just stop the APT completely? Why doesn't he put his money where his mouth is? ;)

Same goes for 6 months or whatever time before the end of the minimal 12-month post-DES APT period.
 
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Let me put it this way: if the cardiologist thinks the patient is not at risk for stent thrombosis after only 3 months of APT, that the stent has already endothelialized, why doesn't he just stop the APT completely? Why doesn't he put his money where his mouth is? ;)

Same goes for 6 months or whatever time before the end of the minimal 12-month post-DES APT period.


In my practice we use 6 months and Cardiac Clearance for elective surgery after DES placement. I believe the evidence supports that decision as do most of the Cardiologists. If a "rogue" Cardiologist wants to "clear" a patient for surgery only 3 months after DES placement that is incorrect based on our current body of knowledge. However, if the Cardiologist wants to be conservative and wait 12 months that is fine with me.

Since this discussion is meant to share information I see little point in arguing over one's approach here: Either go with 6 months (based on recent data and Cardiology input) or wait the standard 12 months.
 
My problem, Blade, with this approach is this: if the patient is still on Plavix, then the patient still has risk for thrombosis, be it 6, 12 or 18 months after DES. If the cardiologist thinks that the stent has endothelialized, he should stop the Plavix forever, not just for one week. If he doesn't, than why the heck would I accept the risk of the patient having an MI on my watch?

In my experience, most cardiologists know absolutely **** about what happens in the OR.
 
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He was especially upset because he has to pay the new deductible.
This is an interesting problem, and something for us to remember when we cancel (er, postpone) cases.

Sometimes there's a major financial impact on a patient if you put off the surgery. Not just lost work, and screwed up family arrangements, but maybe $1000s in a new calendar year's insurance deductable.

I'm not saying I'd do an elective case in someone with a fresh DES, that's a no kidding, no negotiation, hard Cancel with a capital C. But just a week ago I witnessed the softest of soft cancels ... 20-something yo ASA 1 getting an outpatient ortho procedure, canceled because he had some sinus congestion. There was real damage to this guy in terms of lost work and life rearrangement for him, his family, and his employer now that he can't recover over the holidays and be back at work in January. It'd be even worse if he had a fresh deductable to deal with on Jan 1st.


I am considered something of a cowboy. I push the line on doing cases just about as far as it can be reasonably pushed.
Me too ...

If after explaining to the patient the risks and the concerns you have the patient still insists on proceeding with the surgery, and assuming the patient is a mentally competent adult, you should document your discussion with the patient and proceed with the surgery.

... but I can't agree with this. That consent is defense against criminal battery, not malpractice.
 
... but I can't agree with this. That consent is defense against criminal battery, not malpractice.
In the US, mostly.

In many other countries, if you are properly informed about the risks and you assume them, and something bad happens, it's not malpractice (unless there is some intraop egregious error). That's how it should be in the US, too, but then all those poor lawyers could not contribute all that money to the political parties anymore...

When a legally competent patient assumes a risk, it should be the patient's risk, not the physician's. It's logic 101.
 
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But just a week ago I witnessed the softest of soft cancels ... 20-something yo ASA 1 getting an outpatient ortho procedure, canceled because he had some sinus congestion. There was real damage to this guy in terms of lost work and life rearrangement for him, his family, and his employer now that he can't recover over the holidays and be back at work in January. It'd be even worse if he had a fresh deductable to deal with on Jan 1st.
That might be by some book, but it sounds like borderline incompetent and lazy.
 
Clopidogrel, prasugrel, and ticagrelor should be stopped five, seven, and three to five days, respectively, before surgery. Some experts are willing to recommend shorter discontinuation periods, for procedures less likely to be associated with major bleeding.


OFF TOPIC BUT...

The AHA/ACC plavix 5 day rule, and the ASRA neuroaxial 7 day rule (or 5 days with documented platelet function test) has caused major issue with our ortho cases. We do tons of ortho at my hosptial.
I've performed a general on a lot of Pts that probably would of benefited from a spinal because they stopped plavix for 5 days. Running that lab is expensive and takes forever. It isnt practical unless general could cause severe morbidity/mortality.

Surgeons know we want 7 days, however private cardiologists don't know our preferences.

Either ASA needs to revise guidelines, or surgeons/cardiologists should still recommend 7 days.
 
In the US, mostly.

In many other countries, if you are properly informed about the risks and you assume them, and something bad happens, it's not malpractice (unless there is some intraop egregious error). That's how it should be in the US, too, but then all those poor lawyers could not contribute all that money to the political parties anymore...

When a legally competent patient assumes a risk, it should be the patient's risk, not the physician's. It's logic 101.

Playing devil's advocate, because that's what I like to do :), I don't fully agree with that logic 101. Even the smartest "legally competent" patients are unqualified to assess medical and surgical risks and benefits, and depend heavily on us to do that assessment for them, and advise them. When there are multiple options, all within the standard of care, then of course we should defer to the patient's preferences. But doctors shouldn't be doing dangerous stuff outside the standard of care, just because a patient wants it.

We're talking about this in another thread now, the Jahi McMath one. The family of "legally competent" people wanted (demanded!) that a procedure be done on a brain dead kid. That's crazy, it's well outside the standard of care, and most of us objected to it, and that patient is DEAD.

I'm all for deferring to patient wishes but I'm not in the assisted suicide business.
 



The AHA/ACC plavix 5 day rule, and the ASRA neuroaxial 7 day rule (or 5 days with documented platelet function test) has caused major issue with our ortho cases. We do tons of ortho at my hosptial.
I've performed a general on a lot of Pts that probably would of benefited from a spinal because they stopped plavix for 5 days.


The actual measurable benefit to any given patient from a spinal compared to a general is quite small and if they aren't off anticoagulants I don't lose any sleep over it. If they are a pulmonary cripple and would see a potential large benefit, I have a long discussion with them and we come up with a plan. That plan might be do the spinal anyways, postpone surgery, or proceed with GA.
 
Current NEJM.

Dual therapy after DES 3yrs to 1 yr. Decreased thrombosis but increased bleeding.
 
We are paid to do cases. If you refuse to do the case because the patient is only 6 months out from his DES and he has a note from his Cardiologist Clearing him for this elective case then I step in to do the case. In the real world we don't cancel cases unless there is OBJECTIVE data to support cancellation. The published data and the Cardiology note is more than enough to do the case at 6 months post DES.
 
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CONCLUSIONS
Dual antiplatelet therapy beyond 1 year after placement of a drug-eluting stent, as compared with aspirin therapy alone, significantly reduced the risks of stent thrombosis and major adverse cardiovascular and cerebrovascular events but was associated with an increased risk of bleeding.


http://www.nejm.org/doi/full/10.1056/NEJMoa1409312

Based on FFP's logic should we wait 2 years or even 2.5 years to do the case? Will the risk ever become zero? It's reasonable to discuss the SMALL/SLIGHT increased risk to the patient by doing his elective Knee at 6 months vs 1 year but the risk of a MACE will never reach zero.


"An elevated risk of stent thrombosis and myocardial infarction was observed in both groups during the 3 months after discontinuation of thienopyridine treatment."
 

OFF TOPIC BUT...

The AHA/ACC plavix 5 day rule, and the ASRA neuroaxial 7 day rule (or 5 days with documented platelet function test) has caused major issue with our ortho cases. We do tons of ortho at my hosptial.
I've performed a general on a lot of Pts that probably would of benefited from a spinal because they stopped plavix for 5 days. Running that lab is expensive and takes forever. It isnt practical unless general could cause severe morbidity/mortality.

Surgeons know we want 7 days, however private cardiologists don't know our preferences.

Either ASA needs to revise guidelines, or surgeons/cardiologists should still recommend 7 days.


I've done a few spinals for surgery even though the patient was off plavix for just 5 days. If the Pt/ptt is normal, Platelets over 100,000 and the Plavix test is fine then I do the SAB.
http://www.accumetrics.com/products
 
Br J Anaesth. 2011 Dec;107(6):966-71. doi: 10.1093/bja/aer298. Epub 2011 Oct 3.
Determination of residual antiplatelet activity of clopidogrel before neuraxial injections.
Benzon HT1, McCarthy RJ, Benzon HA, Kendall MC, Robak S, Lindholm PF, Kallas PG, Katz JA.
Author information

Abstract
BACKGROUND:
Guidelines recommend discontinuation of clopidogrel for 7 days before a neuraxial injection, while other directives suggest that 5 days might be adequate. We examined the time course of antiplatelet activity after clopidogrel discontinuation in patients undergoing epidural injections.

METHODS:
Thirteen patients were studied at baseline, 3, 5, and 7 days after discontinuation of clopidogrel. P(2)Y(12) determinations were performed using the VerifyNow(®) assay (Accumetrics, San Diego, CA, USA), and clot closure times with stimulation by collagen/epinephrine and collagen/adenosine diphosphate using the PFA-100(®) (Platelet Function Analyzer, Siemens Diagnostics, Deerfield, IL, USA). Repeated-measures ANOVA was used to evaluate P(2)Y(12) platelet reaction units, PFA-100 closure times, and per cent P(2)Y(12) inhibition values. Wilcoxon's signed-rank test was used to compare the frequencies of ≥30%, 11-29%, and ≤10% platelet inhibition between the baseline and subsequent sampling points after discontinuation of clopidogrel.

RESULTS:
On day 3 after clopidogrel discontinuation, two subjects had ≥30%, seven subjects had 11-29%, and four subjects had ≤10% platelet inhibition; the corresponding numbers were 0, 3, and 10 subjects on day 5 (P=0.04). There were no differences between the ≥30%, 11-29%, and <10% platelet inhibition groups between days 5 and 7 (0, 0, and 13 subjects, P=1.0). PFA-ADP closure times were normal throughout the study period except in one patient.

CONCLUSIONS:
These findings support the recommendation that discontinuation of clopidogrel for 5 days allows >70% of platelet function and might be adequate before a neuraxial injection is performed.
 
I've done spinals with patients only off clopidogrel for 4-5 days if they had a big benefit to the spinal and coags were otherwise normal. The risk of epidural hematoma from a single shot spinal is extremely low, even with platelet function partially inhibited.
 
CONCLUSIONS:
These findings support the recommendation that discontinuation of clopidogrel for 5 days allows >70% of platelet function and might be adequate before a neuraxial injection is performed.

I agree with this conclusion full heartily. Nice that you actually found a study on it.

However, until ASRA changes their guidelines, I still will avoid spinals on 5 day plavix unless general may cause severe morbidity/mortality. Our ortho guys hate general and say it causes way more bleeding. Plus it makes a huge difference in cognitive recovery of 85 year old grandma with broken hip when you do a spinal and a touch of propofol vs LMA with sevo running for couple hours.
 
Plus it makes a huge difference in cognitive recovery of 85 year old grandma with broken hip when you do a spinal and a touch of propofol vs LMA with sevo running for couple hours.

You know, I used to believe this too. I don't anymore. I believe there may be a small difference, but not a huge one.

In our group that does TAVRs, one guy uses a pure propofol TIVA, I use pure desflurane. We've looked at it, and there isn't a shred of difference in our neurocognitive outcomes.
 
The biggest risk for an elderly hip fracture patient in developing postop dementia is simply being in the hospital. Sundowning, ICU delirium, call it what you want. Having surgery with some form of anesthetic is a contributor, but it isn't the biggest contributor. The several day hospitalization and polypharmacy and pain are the bigger contributors.
 
We are paid to do cases. If you refuse to do the case because the patient is only 6 months out from his DES and he has a note from his Cardiologist Clearing him for this elective case then I step in to do the case. In the real world we don't cancel cases unless there is OBJECTIVE data to support cancellation. The published data and the Cardiology note is more than enough to do the case at 6 months post DES.

I agree with your sentiment about cancelling cases but it is very poor forum to do a case that a partner refuses (although the poor forum may reflect more on a partner if they cancel for a weak reason).
 
However, until ASRA changes their guidelines, I still will avoid spinals on 5 day plavix unless general may cause severe morbidity/mortality.

I agree.

Our ortho guys hate general and say it causes way more bleeding.

Hmmm, same ortho guys who ask for more muscle relaxant in ankle cases with a nerve block and tourniquet? :)

Plus it makes a huge difference in cognitive recovery of 85 year old grandma with broken hip when you do a spinal and a touch of propofol vs LMA with sevo running for couple hours.

I don't believe that from my own experience, and the data certainly doesn't support the claim of a huge difference. I prefer GA + FI blocks for my old hips.
 
... but I can't agree with this. That consent is defense against criminal battery, not malpractice.

Patients have the right to make decisions regarding their health care and your role is to provide them with the information necessary to make these decisions in an educated way.
For example if a patient decides to be DNR and you find yourself in a situation where you know that intubating that patient would save his life you wouldn't violate his wishes and intubate him would you?
 
Patients have the right to make decisions regarding their health care and your role is to provide them with the information necessary to make these decisions in an educated way.
For example if a patient decides to be DNR and you find yourself in a situation where you know that intubating that patient would save his life you wouldn't violate his wishes and intubate him would you?
Autonomy to refuse care is entirely different than autonomy to demand or consent to inappropriate care.

For example if a patient decides that having opposable thumbs makes his life too easy and you find yourself in a situation where he wants you to anesthetize him so someone can cut off his thumbs you wouldn't adhere to his wishes and take him to the OR would you?

Consent doesn't legally protect you from malpractice, and it doesn't morally protect you from doing something terrible that's not in the best interest of the patient.
 
Autonomy to refuse care is entirely different than autonomy to demand or consent to inappropriate care.

For example if a patient decides that having opposable thumbs makes his life too easy and you find yourself in a situation where he wants you to anesthetize him so someone can cut off his thumbs you wouldn't adhere to his wishes and take him to the OR would you?

Consent doesn't legally protect you from malpractice, and it doesn't morally protect you from doing something terrible that's not in the best interest of the patient.
So, let's say you work at a surgery center and you do a lot of plastic and cosmetic surgery, would you refuse to provide anesthesia to these patients unless their surgery had a medical indication and no serious side effects?
and if you do, how long you think you are going to remain employed?
 
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