A few of my recent cases I considered cancelling

[Dinkyconductor]

So, as a new (6 months now) attending, I've found it difficult to decide when to cancel an elective case. A lot of the difficult cases that have been brought up on this board recently were emergencies and not subject to cancellation (e.g. the bleeding AAA, the 95 year old woman for emergent BKA). I wanted to bring up a few tricky ones I've encountered lately and see whether people would have asked that the case be cancelled for further workup. I should also note that the answer I might give on boards (cancel anytime the patient is not optimized) might not be what I do in real life (e.g. I'd be unlikely to delay a patient on digoxin for a potassium of 3.1, even though the book answer is that you should)

-Healthy 50yo woman for laparoscopic hysterectomy, nothing on history/physical. Routine labs (ordered by the surgeon's office on every patient) showed a PTT of 57. Repeated the lab with a second blood draw, same number. No clinical correlation with bleeding, no family history, nothing else.

-50yo woman for open hysterectomy, no major history except routine screening labs (which have not been seen by her primary care physician) show a TSH of <0.01. On history, she denies any symptoms of hypo/hyperthyroid, nothing on physical exam, but she says she thinks she had some thyroid problem twenty years ago, she thinks she was on synthroid for a few weeks then was told to stop taking it. We don't have any other thyroid-related labs, and the other routine labs are normal.

-55yo woman for total knee, she's kind of crazy. She notes in her survey that she takes 40 aspirin tablets a day, and has done so for ten years. I probe this a bit, and yes, she basically takes a 325mg aspirin every twenty minutes, every day. She runs through a whole bottle every two days. When I suggest this might not be a good idea, she angrily claims it's the only thing that helps her arthritis, and that her primary care doctor knows all about it and encourages it. Although I didn't really remember all that much about signs of aspirin overdose, there was nothing obvious on H&P to suggest badness (no tinnitus, bleeding issues, etc.) I don't think there was anything too remarkable in her labs.

-50yo woman for x-lap for ovarian cancer. When I walk up to meet her she's snoring away, turns out she has textbook severe sleep apnea: snoring, daytime somnolence, apnea noticed by spouse, the works. Room air sat is around 95%. She thinks someone had mentioned this sometime before, but she's never done anything about it or seen anyone about it.

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[Planktonmd]

1- The woman with increased PTT: Most likely has antiphospholipids syndrome and these patient have increased PTT although they are actually hypercoagulable, I would have canceled her and requested hematology consult.
2- The woman with the low TSH: although there is no symptoms I want to know if she is hyperthyroid so I would have canceled her.
3-The Aspirin lady: She will not stop her aspirin regardless of what you do, so I would do the case and maybe give her some platelets pre-op.
4- The sleep apnea lady: No problem.

 

[johankriek]

all borderline.. not everyone will be perfect... I would delay the first case for a medical consult.. ( you dont want to get into oozing issues especially in that area
4 might merit a delay until results of a bleeding time come in..


the others I think i would do.

 

[militarymd]

Assuming your surgeons are like my surgeons, I would not have cancelled any of the cases because these patients had labs that I would never have ordered preoperatively...so I would not have know the results to have cancelled them.

But because they did have the labs done...they should be followed up by whoever ordered them.

The lady with possible APL syndrome...MAY benefit from additional DVT prophylaxis ...that's it...no other therapy is indicated without prior history of thrombosis.

As for the ASA abuser...I may check a serum bicarb before going to the OR just to document acid base status before starting surgery..

 

[Idiopathic]

Some thoughts, even though Im not an attending.

TSH usually ordered with T4, so you would be able to tell hyperthyroid vs. primary hypo vs. euthyroid? Shouldnt be a problem anyway unless clinically hyper.

How can you possibly do that aspirin lady? It wont show up on PT/PTT, I doubt you did a bleeding time. You would essentially be starting from 0 effective platelets.

 

[sevodude]

2. do as she is completley asymptomatic
4. Do lots of patients have sleep apnea
1,4 Do the patients show any signs of bleeding disorders? bruising inability to stop bleeding from cuts, blood on gums from brushing teeth? If no then go.

 

[deleted126335]

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[urge]

-Healthy 50yo woman for laparoscopic hysterectomy, nothing on history/physical. Routine labs (ordered by the surgeon's office on every patient) showed a PTT of 57. Repeated the lab with a second blood draw, same number. No clinical correlation with bleeding, no family history, nothing else.

She could have von Willebrand disease too. I wouldn't start treating a lab value without a diagnosis. Canceled

The lady with low TSH -canceled too.

The other 2 I would do.

 

[Planktonmd]

Some thoughts, even though Im not an attending.


How can you possibly do that aspirin lady? It wont show up on PT/PTT, I doubt you did a bleeding time. You would essentially be starting from 0 effective platelets.

Yes, and that's why you give her platelets and do the case.

 

[Planktonmd]

1,4 Do the patients show any signs of bleeding disorders? bruising inability to stop bleeding from cuts, blood on gums from brushing teeth? If no then go.

Are you saying if a patient is not bleeding spontaneously then it's OK for them to have elective surgery?
So, is it OK to do elective surgery on someone receiving Warfarin and has an INR of 5 but has no symptoms of spontaneous bleeding and did not have any cuts recently to tell you if he would bleed for a long time?
How about a patient that just received a thrombolytic agent, he is not showing any signs of spontaneous bleeding, can we go ahead and do elective surgery on him?

 

[militarymd]

Are you saying if a patient is not bleeding spontaneously then it's OK for them to have elective surgery?
So, is it OK to do elective surgery on someone receiving Warfarin and has an INR of 5 but has no symptoms of spontaneous bleeding and did not have any cuts recently to tell you if he would bleed for a long time?
How about a patient that just received a thrombolytic agent, he is not showing any signs of spontaneous bleeding, can we go ahead and do elective surgery on him?

kettle here....calling pot......you're talking about different patient populations...

 

[TIVA]

I'd probably do all the cases ... ignorance is bliss. 😛

But with respect to 1 (elevated PTT) and 3 (high aspirin intake), I'd proceed as long as the surgeons were happy to proceed. Different surgeons have different thresholds of tolerance for coagulopathy for different surgical procedures, and thus, it's more their call than mine.

On the other hand, if the surgeons looked to me for advice, I'd proceed with case 1, and postpone case 3 because platelet transfusions are potentially lethal (something not small, like 1-5% of cases), and if I can avoid giving them, I would (I've seen too much badness with them). I'd ask the lady to take some other form of pain killer for the next 10-11 days at which point we'd bring her back.

 

[sevodude]

Do you really know they are taking the asparin? If they are asymptomatic no bruising, no prolonged bleeding from cuts or minor trauma then ho,eostasis is being maintained. What is the patient like? Not wehat a number alone says.
I was not talking about no spontaneous bleeding.

 

[Planktonmd]

I'd ask the lady to take some other form of pain killer for the next 10-11 days at which point we'd bring her back.

She either won't listen to you or lie to you.

 

[Planktonmd]

Do you really know they are taking the asparin? If they are asymptomatic no bruising, no prolonged bleeding from cuts or minor trauma then ho,eostasis is being maintained. What is the patient like? Not wehat a number alone says.
I was not talking about no spontaneous bleeding.

If they say they are taking aspirin then they are taking aspirin!
I just gave you 2 examples of asymptomatic people who you probably wouldn't do elective surgery on.
When it comes to hematologic problems "Numbers" are all you have sometimes.

 

[sevodude]

If the patient is asymptomatic to minor trauma then you have more then a number as for transfusing platlets there is proof that will help.

Role of transfusion
There are no clinical studies validating the benefits of
platelet transfusion in reducing the risk of bleeding
(prophylactic administration) or in limiting bleeding
when it occurs (therapeutic administration) in patients
with drug induced thrombopathy. However, this is the
only therapeutic option that can be envisaged in the​

event of severe hemorrhage (Professional Consensus).
2003 canadian journal of anesthesia.www.cja-jca.org/cgi/reprint/52/1/30.pdf

 

[Planktonmd]

If the patient is asymptomatic to minor trauma then you have more then a number as for transfusing platlets there is proof that will help.

Role of transfusion
There are no clinical studies validating the benefits of
platelet transfusion in reducing the risk of bleeding
(prophylactic administration) or in limiting bleeding
when it occurs (therapeutic administration) in patients
with drug induced thrombopathy. However, this is the
only therapeutic option that can be envisaged in the​

event of severe hemorrhage (Professional Consensus).
2003 canadian journal of anesthesia.www.cja-jca.org/cgi/reprint/52/1/30.pdf

What is your definition of minor trauma?
What if the patient did not have minor trauma?
What is the connection between minor trauma and surgery?
And when it comes to platelets transfusion i did not claim that it is mandatory preop, you can always wait until they start bleeding then give it but I think it makes more sense to give it initially in a patient who is on huge doses of aspirin because there is nothing else you can do.

 

[gudog]

Instead of a bleeding time to evaluate these patients who may or may not have coagulation problems, I have been doing a "plavix assay" which measures the percent of platelets that are inhibited (from whatever cause).

Subtract the number of inhibited platelets from the total count, and you have the number of active platelets present, from which you can decide what to do.

Bleeding times are no longer done at my hospital.

Note, I am a surgeon, not an anesthesiologist, pardon me for butting in.

 

[militarymd]

Instead of a bleeding time to evaluate these patients who may or may not have coagulation problems, I have been doing a "plavix assay" which measures the percent of platelets that are inhibited (from whatever cause).

Subtract the number of inhibited platelets from the total count, and you have the number of active platelets present, from which you can decide what to do.

Bleeding times are no longer done at my hospital.

Note, I am a surgeon, not an anesthesiologist, pardon me for butting in.

welcome....Please do butt in....no point being an anesthesiologist if there're no surgeons around.

 

[Tenesma]

bleeding times are useless

agree with plavix assay but costly and not all community hospitals can do them

i agree that most of these cases are surgical issues for cancellation - and really have nothing to do with the anesthetic (except for the thyroid and the apnea patient)...

i have run into bad things (including asystole) with uncontrolled thyroids in the past...

would do the apnea patient - come on --- what's the worst thing that can happen? of course i would insist on an epidural to minimize her post-operative opioids...

 

[2ndyear]

Interesting malpractice case recently, I'll provide the link after the post. A little different as the record wasn't even reviewed, but worth stating anyways:

Failure to review a medication list results in a judgment of $700,000 when a patient taking a NSAID developed a post operative spinal cord hematoma with residual weakness in both legs and no bowel or bladder control after lumbar laminectomy surgery. The anesthesiologist’s argument that it was not a breach of the standard of care to not read the medical record prior to surgery and that the anesthesiologist had no duty to discuss the drug with the surgeon was not accepted by the jury (Barbour v. Betz, June 2004). In this case, as in other cases I have seen, defenses based on the concept that “it was not my responsibility” to know a particular piece of information about a patient has not been well accepted.

http://upennanesthesiology.typepad.com/upenn_anesthesiology/2007/08/recent-medical-.html

 

[Dinkyconductor]

Thanks, all, for the comments....the lack of consensus is reassuring, since I was torn on each of these. Here's what I did:

-The PTT woman: As I said, I repeated the lab, same number. I disagreed that it was only a surgical issue. If the patient had starting bleeding uncontrollably intraop, what would I have done? Given FFP? I wouldn't have known how to treat it, since I wouldn't have known what was wrong. So, I was on my way to cancel it, when my partner relieved me (it was 7pm), who proceeded to do the case anyway. Everything turned out fine (though I still think cancelling was the best option).

-Thyroid: I was mainly worried about thyroid storm or some other disaster. But, since she had no symptoms, I thought it was really unlikely to be an issue, so I did the case and told her to follow up post-op to have it looked into. Pt did fine.

-Aspirin: We actually ended up cancelling her for an unrelated reason I intentionally didn't mention (cardiologist note said she would need a stress test that she never got). Had this not come up, I would have first called her PCP to get the real story...then I probably would have done the case had the surgeon been OK with it. I 'd have to say I don't understand plankton's rationale of giving platelets...she's been taking aspirin up until today, won't the residual aspirin in her system just inhibit the new platelets? Maybe if you give enough platelets, you would overwhelm the aspirin...I have no idea.

-Sleep apnea--reason I brought this up was that we had a grand rounds on OSA the week before...I looked through some review articles, and some think you should treat the OSA (with CPAP or even corrective surgery) before elective surgery. There doesn't seem to be a consensus on this. Still, I did an epidural and gave her no narcotics to minimize sedation/obstruction. Pt did fine.

Now, remember that just because a patient did fine doesn't justify the course of action taken ("post hoc ergo propter hoc" reasoning), so I may have been totally wrong in going ahead with the thyroid case.

Thanks for the input.

 

[Planktonmd]

I 'd have to say I don't understand plankton's rationale of giving platelets...she's been taking aspirin up until today, won't the residual aspirin in her system just inhibit the new platelets? Maybe if you give enough platelets, you would overwhelm the aspirin...I have no idea.

.

The half life of aspirin in the plasma is 20 minutes after absorption and the half life of Salisylates is 3-4 hours, so if you manage to keep her off aspirin for 3-4 hours your transfused platelets should be OK.

 

[Dinkyconductor]

Oh, thanks! Learned something new.

 

[BADMD]

-Aspirin: We actually ended up cancelling her for an unrelated reason I intentionally didn't mention (cardiologist note said she would need a stress test that she never got). Had this not come up, I would have first called her PCP to get the real story...then I probably would have done the case had the surgeon been OK with it. I 'd have to say I don't understand plankton's rationale of giving platelets...she's been taking aspirin up until today, won't the residual aspirin in her system just inhibit the new platelets? Maybe if you give enough platelets, you would overwhelm the aspirin...I have no idea.

One thing to consider (coming from a Toxicologist and not an anesthesiologist) is that she might have chronic salicylism. If she has significant ASA levels (even as low as 30-40) she might be far more sensitive to hypercarbia. Smallish downward changes in her pH may cause large shifts of aspirin from the blood into the CNS. If you do this case, you need to keep very tight control of her CO2, especially during induction.

 

[johankriek]

But because they did have the labs done...they should be followed up by whoever ordered them.

..

and that person is YOU the anesthesiologist who is charged with reviewing her ENTIRE record. I know we dont do that. But thats what they will see the jury.
if they have labs done regardless of who ordered it for whatever reason.. its YOUR responsibility to review them and take action.. pretty important point in which I dont follow to the fullest either.. thats why it is vitally important never to order labs that you are not interested in. If you want to know the Hemoglobin, order a hemoglobin, not a cbc with differential. If you wanna know what the K is order a k and not a comp metabolic panel.

 

[DrDre']

Mil, that is a hil-hairy-azz statement!

welcome....Please do butt in....no point being an anesthesiologist if there're no surgeons around.

 

[Ketamininus]

Well, like some who have chosen to respond, I am also not an Attending but I'll answer based on my experience and contribution to the lack of consenus.

1. No way I do this case. Regardless of the etiology, I can't ignore the PTT result. While the chances are that the case would go just fine and without complication, if she did have a problem then I'm totally hung out to dry by not catching that before surgery. Cancelled. Get a workup and come back when it's known why that PTT is that high.

2. Cancelled, for similar reasons as 1. I can't ignore the number without a workup of some kind. If she goes all thyroid storm on me, I'll be struggling more with damage control than if someone at least consults on this issue and gives me a recommendation. Beta-block her and do the surgery? Fine, but I want that in writing and on the chart before she goes to sleep.

3. She's on how much aspirin?? That's a truckload, and she probably has 50 working platelets in her body at any given time. If my hospital offers a PFA (platelet function assay) that can be done while she waits to go back for surgery, I'll do that and await the result. If it's OK, I'll do it. If not, she's cancelled and can come back after she discontinues her ASA for the recommended time. Yeah, she may come back and lie to me about it...but then it's the patient who's putting herself in harm's way by lying to her clinicians. If I take her back and she bleeds, it could be a disaster. Likely canceled.

4. We get these clinically obvious but undiagnosed OSA patients all the time. Treat them as if they are OSA and do the case. This one's a go.

So, I just PO'd 3 surgeons and had one who'll not be disgusted with me...for a day. At least I did what I thought was the clinically correct and safe thing for the others. My $0.02, anyway.

- Ket

 

[militarymd]

Mil, that is a hil-hairy-azz statement!

Do you not agree?

 

[militarymd]

and that person is YOU the anesthesiologist who is charged with reviewing her ENTIRE record. I know we dont do that. But thats what they will see the jury.
if they have labs done regardless of who ordered it for whatever reason.. its YOUR responsibility to review them and take action.. pretty important point in which I dont follow to the fullest either.. thats why it is vitally important never to order labs that you are not interested in. If you want to know the Hemoglobin, order a hemoglobin, not a cbc with differential. If you wanna know what the K is order a k and not a comp metabolic panel.

and you are correct...100%...and that is why I arrange follow up for my patients with physicians who I have personal/professional relationships with to make sure that nothing is missed.

I arrange the follow up....help my buds out with business...AND at the same time cover my ass from the medical/legal perspective....NOT that it has ANYTHING to do with good care.

 

[Planktonmd]

If my hospital offers a PFA (platelet function assay) that can be done while she waits to go back for surgery, I'll do that and await the result. If it's OK, I'll do it. If not, she's cancelled - Ket

PFA is an in vitro attempt to measure platelet aggregation and no one knows if it has any clinical value other than the Miami company that makes the kit.

 

[DrDre']

Of course, I agree. That's why I said it was funny. Not much point putting people to see just for the hell of it!

Do you not agree?

 

[elwademd]

as far as the elevated ptt issue goes, it's either lupus anticoagulant which is interfering with the lab test, or she has a factor deficiency- specifically 8, 9, 11, or 12. given a normal pt, deficincies of factor 7, 10, 5, and 2 are ruled out.

she's never had a bleeding issue, which seems to make the issue a sort of non-issue. but in any event, a deficiency of factor 12 is rare, and it doesn't lead to bleeding. it only causes an elevated ptt. and as pointed out, having lupus anticoagulant on board wouldn't lead to bleeding, but rather clotting.

so that really only leaves you with a true worry about factors 8, 9, or 11... all of which most hematologists would just have you use fresh frozen plasma to replace at the time of surgery.

someone mentioned a thought about von willebrand's deficiency, but that doesn't lead to a rise in ptt (nor pt), and can only be found if specificially ordered... or a detailed history about uncontrolled bleeding with prior surgeries or dental procedures.

 

[drccw]

3. She's on how much aspirin?? That's a truckload, and she probably has 50 working platelets in her body at any given time. If my hospital offers a PFA (platelet function assay) that can be done while she waits to go back for surgery, I'll do that and await the result. If it's OK, I'll do it. If not, she's cancelled and can come back after she discontinues her ASA for the recommended time. Yeah, she may come back and lie to me about it...but then it's the patient who's putting herself in harm's way by lying to her clinicians. If I take her back and she bleeds, it could be a disaster. Likely canceled.



- Ket

My hospital has PFA.. anytime we order it though by the time the result comes back the surgeons have already given platelets...

Would anyone have looked at a TEG?

 

[Planktonmd]

My hospital has PFA.. anytime we order it though by the time the result comes back the surgeons have already given platelets...

Would anyone have looked at a TEG?

Why?
She is on huge doses of Aspirin, do you expect her platelets function to be normal?

 

[drccw]

I dont.. but the surgeons do...