Another case to discuss

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Noyac

Noyac

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76yo M for L4/5-5/1 PSF with decompression.
Pt had MI with stent placement 3 months ago. Poor exercise tolerance, one flight of stairs SOB and leg cramping.
Stress Echo 2months this after stent and MI:
-no evidence of ischemia
-normal wall motion with EF 72%
-vitals during stress test 157/93 HR 116 max ( why does this matter and what does 20,000 value mean?)

Gupta-0.76

Cleared by cardiology

Plavix and ASA held 7days.

Pt is here for surgery at 7:30am.
 
Let's ignore the MI for a moment. Unless the stent is bare metal, cardiology can clear their throat, and nothing else, in this case. I personally would not do it, for the periop thrombotic risk, unless it's emergent (and I do ASA 4s all the time). I don't do death by anesthesiologist. DAPT held for 7 days within 3 months of a DES? I am speechless.

I would kindly point the surgeon to the ACC/AHA guidelines, with an extra copy for the "cardiologist". There is no excuse for doing an elective procedure within 6 months. Even beyond 180 days, only " if the risk of further delay is greater than the expected risks of ischemia and stent thrombosis".

Now add the MI, which is a risk factor for periop stroke in the first 6 months (meaning 8-times increase in periop mortality rate). I guess you can't make this stuff up.

One of the places I worked at had their own list of approved specialists who were allowed to clear patients for surgery. Now I see why.
 
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dhb said:
They do have new stents that allow for 3 months of therapy.
Click to expand...
Show me the guidelines, and I'll show you mine. 🙂

I am sure those 3 months are not for purely elective surgeries. There is no way the benefits exceed the risks.

"For patients who have undergone previous stenting with either BMS or DES and who will need cessation of one or both antiplatelet agents, we defer planned non-emergent noncardiac surgery until after the recommended duration of DAPT, which is six months for BMS and DES. The risks of noncardiac surgery before six months are increased after both BMS and DES.

For patients whose surgery cannot wait and where the risks of delaying surgery outweigh that of stent thrombosis, our recommended minimal duration of DAPT is three months for both BMS and DES [33]. This is based in part on evidence suggesting that the increased risk of MI and cardiac death is highest within the first month after stent placement and no clear difference in risk between BMS and DES [32,34]. In patients for whom surgery before three months is in their best interest after weighing risks and benefits, we sometimes refer patients as early as one month after stent placement."

UpToDate (May 14, 2018)

Btw, the Gupta score doesn't take recent MI or stent into consideration. So I couldn't care less that the supposed "Estimated Risk Probability for Perioperative Myocardial Infarction or Cardiac Arrest" is under 1%.
 
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Spend an extra 3 minutes to discuss with patient's wife (that's the person that will sue you if he dies) about her husband high risk of another MI during the operation. Preinduction arterial line, maybe 2nd IV if slow surgeon, and get on with your day.
 
Preinduction A-line in a patient with EF of 72%? Seriously? And that will prevent his stent thrombosis?

The jury will not forgive us for giving a patient an option he should have never been given in the first place (that's what the lawyer will argue). This ain't Europe. Our patients are considered (by our laws) too stupid to decide that certain risks are simply worth taking. That's why they are not allowed to wave their right to sue for malpractice.
 
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FFP said:
Preinduction A-line in a patient with EF of 72%? Seriously? And that will prevent his stent thrombosis?
Click to expand...

Seriously, it's not for the EF of 72%, I want a normal BP during induction instead of the usual hypotension. If any one would look at my anesthetic, they can't blame the induction as a reason why this guy did poorly during the operation. All it takes is an extra 2-3 minutes to put one in while he is in holding area.
 
marr65 said:
Seriously, it's not for the EF of 72%, I want a normal BP during induction instead of the usual hypotension. If any one would look at my anesthetic, they can't blame the induction as a reason why this guy did poorly during the operation. All it takes is an extra 2-3 minutes to put one in while he is in holding area.
Click to expand...
Hypotension does not cause stent thrombosis (plus, respectfully, it takes a below average anesthesiologist to induce significant peri-induction hypotension with an EF of 72). By this logic, we should put A-lines in every potentially litigious patient, even for a colonoscopy.

Put the cuff q2 min during induction, and q3 min during surgery, run a phenylephrine drip, and it's very likely that the patient will be easily kept stable (unless he thromboses or the surgeon loses a lot of blood).
 
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FFP said:
I am sure those 3 months are not for purely elective surgeries. There is no way the benefits exceed the risks.
Click to expand...

This surgery might not be totally elective. If he's losing neurologic function, it falls more into the urgent category.
 
Mman said:
This surgery might not be totally elective. If he's losing neurologic function, it falls more into the urgent category.
Click to expand...
And then it's a completely different discussion. And I mean literally a discussion with surgeon and patient. But I need that documented first. E.g. "By postponing the surgery, even by 3 months, the patient risks paralysis."
 
And it's not even like the risk plummets to 0 from 6 months post stent, it just happens to fall below what we've decided to call an acceptable level.
 
What if, for sake of argument, same patient has low EF around 25 percent, mild to moderate pulmonary htn, multiple medical comorbidities and neurosurgeon is pushing hard to proceed for a weak indication such as a longstanding radiculopathy with 3-4/5 unilateral motor deficit.


Would you proceed or hold off?

Similar but unrelated, we have a neurosurgery group would go to the same cardiologist for clearance who nearly always stated in their note " high risk patient undergoing high risk surgery though I think no ischemic workup is indicated as it will not change management, please avoid hypertension, hypotension blah blah". Almost never cancelled these unoptimized trainwreck cases and explicitly stated that no further workup necessary. Very infuriating. Neurosurgery residents surprised how badly some of these patient do post operatively.
 
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FFP said:
Hypotension does not cause stent thrombosis (plus, respectfully, it takes a below average anesthesiologist to induce significant peri-induction hypotension with an EF of 72). By this logic, we should put A-lines in every potentially litigious patient, even for a colonoscopy.

Put the cuff q2 min during induction, and q3 min during surgery, run a phenylephrine drip, and it's very likely that the patient will be easily kept stable (unless he thromboses or the surgeon loses a lot of blood).
Click to expand...

Cycle the cuff every minute during induction, do a slow induction, use phenylephrine. Just don't put in an art line for no real reason😉.
 
marr65 said:
Seriously, it's not for the EF of 72%, I want a normal BP during induction instead of the usual hypotension. If any one would look at my anesthetic, they can't blame the induction as a reason why this guy did poorly during the operation. All it takes is an extra 2-3 minutes to put one in while he is in holding area.
Click to expand...
I don't mean to be rude, but if "usual hypotension" is a part of your inductions for elective surgery then you need to change the way you do inductions.

There is no reason for this patient's vitals to budge more than single digits in either direction peri-induction, a line or no a line.
 
The only way I'd do this case is if he had significant myelomalacia and the case was deemed surgically urgent or emergent. If not, send him to pain for an ESI and come back in 3 months. Just imagine if you ran into some bleeding and had to give products or surgeon requests TXA in a relatively fresh stent off DAPT.

Also, why is this guy short of breath with 1 flight of stairs? Limited mobility from pain or neuropathy I can understand, but I don't like the unexplained dyspnea.
 
Noyac said:
76yo M for L4/5-5/1 PSF with decompression.
Pt had MI with stent placement 3 months ago. Poor exercise tolerance, one flight of stairs SOB and leg cramping.
Stress Echo 2months this after stent and MI:
-no evidence of ischemia
-normal wall motion with EF 72%
-vitals during stress test 157/93 HR 116 max ( why does this matter and what does 20,000 value mean?)

Gupta-0.76

Cleared by cardiology

Plavix and ASA held 7days.

Pt is here for surgery at 7:30am.
Click to expand...

I've already done 2 cases just like this one. I had a Cardiology note "clearing him" for surgery at 3 months. In addition, patient had been off Plavix and ASA for 7 days. I did both cases but just shook my head.
 
With first-generation DES the minimally required DAPT duration was at least 12 months, irrespective of clinical presentation. Newer-generation DES have been designed to overcome most of the limitations of first-generation DES. Overall, new-DES have been shown to be safer than first-generation DES, with a lower risk of ST both in the early-phase and in the long-term (13,14). Convincing evidence has led to a change in both the ESC and the ACC/AHA guidelines, and the period of mandatory DAPT duration after second generation DES has been shortened to 6 months for patients with stable CAD (4,15). Remarkably, based on post-hoc analyses of randomized trials, some stents received the CE (Conformité Européenne) mark labeling for a minimum of 1–3 months DAPT. More recently, a polymer-free biolimus-eluting DES was shown to be superior to bare metal stents (BMS) both in terms of safety and efficacy after a mandatory DAPT duration period of only 1 month among patients at high bleeding risk undergoing PCI, even after an ACS (16). Overall, even if existing clinical data do not support a routine strategy of DAPT shorter than 6 months, last ESC guidelines on management of NSTE-ACS allow P2Y12 inhibitor administration for a shorter duration of 3–6 months after DES implantation in patients deemed at high bleeding risk (17).

Surgery after drug-eluting stent implantation: it’s not all doom and gloom!
 
TheLoneWolf said:
Similar but unrelated, we have a neurosurgery group would go to the same cardiologist for clearance who nearly always stated in their note " high risk patient undergoing high risk surgery though I think no ischemic workup is indicated as it will not change management, please avoid hypertension, hypotension blah blah".
Click to expand...


Sounds like a cardiologist who knows what he’s doing. But that’s not this case.
 
vector2 said:
The only way I'd do this case is if he had significant myelomalacia and the case was deemed surgically urgent or emergent. If not, send him to pain for an ESI and come back in 3 months. Just imagine if you ran into some bleeding and had to give products or surgeon requests TXA in a relatively fresh stent off DAPT.

Also, why is this guy short of breath with 1 flight of stairs? Limited mobility from pain or neuropathy I can understand, but I don't like the unexplained dyspnea.
Click to expand...
Deconditioning (ergo tachycardia with physical effort) plus diastolic dysfunction?
 
BLADEMDA said:
With first-generation DES the minimally required DAPT duration was at least 12 months, irrespective of clinical presentation. Newer-generation DES have been designed to overcome most of the limitations of first-generation DES. Overall, new-DES have been shown to be safer than first-generation DES, with a lower risk of ST both in the early-phase and in the long-term (13,14). Convincing evidence has led to a change in both the ESC and the ACC/AHA guidelines, and the period of mandatory DAPT duration after second generation DES has been shortened to 6 months for patients with stable CAD (4,15). Remarkably, based on post-hoc analyses of randomized trials, some stents received the CE (Conformité Européenne) mark labeling for a minimum of 1–3 months DAPT. More recently, a polymer-free biolimus-eluting DES was shown to be superior to bare metal stents (BMS) both in terms of safety and efficacy after a mandatory DAPT duration period of only 1 month among patients at high bleeding risk undergoing PCI, even after an ACS (16). Overall, even if existing clinical data do not support a routine strategy of DAPT shorter than 6 months, last ESC guidelines on management of NSTE-ACS allow P2Y12 inhibitor administration for a shorter duration of 3–6 months after DES implantation in patients deemed at high bleeding risk (17).

Surgery after drug-eluting stent implantation: it’s not all doom and gloom!
Click to expand...
One cannot quote European guidelines to a jury of "peers".
 
DAPT+and+elective+non-cardiac+surgery.jpg
 
BLADEMDA said:
DAPT+and+elective+non-cardiac+surgery.jpg
Click to expand...
2016 ACC/AHA Guideline Focused Update on Duration of Dual Antiplatelet Therapy in Patients With Coronary Artery Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines - ScienceDirect

Recommendations for Perioperative Management–Timing of Elective Noncardiac Surgery in Patients Treated With PCI and DAPT

COR LOE Recommendations
I B-NR Elective noncardiac surgery should be delayed 30 days after BMS implantation and optimally 6 months after DES implantation 101, 102, 103, 143, 144, 145, 146.

I C-EO In patients treated with DAPT after coronary stent implantation who must undergo surgical procedures that mandate the discontinuation of P2Y12inhibitor therapy, it is recommended that aspirin be continued if possible and the P2Y12 platelet receptor inhibitor be restarted as soon as possible after surgery.

IIa C-EO When noncardiac surgery is required in patients currently taking a P2Y12inhibitor, a consensus decision among treating clinicians as to the relative risks of surgery and discontinuation or continuation of antiplatelet therapy can be useful.

IIb C-EO Elective noncardiac surgery after DES implantation in patients for whom P2Y12 inhibitor therapy will need to be discontinued may be considered after 3 months if the risk of further delay of surgery is greater than the expected risks of stent thrombosis.

III: Harm B-NR Elective noncardiac surgery should not be performed within 30 days after BMS implantation or within 3 months after DES implantation in patients in whom DAPT will need to be discontinued perioperatively 101, 102, 103, 143, 144, 145, 146.

The timing of noncardiac surgery in patients treated with coronary stent implantation involves consideration of: (1) the risk of stent thrombosis (particularly if DAPT needs to be interrupted); (2) the consequences of delaying the desired surgical procedure; and (3) increased the intra- and peri-procedural bleeding risk and the consequences of such bleeding if DAPT is continued 15, 147, 148 (Data Supplement 12). DAPT significantly reduces the risk of stent thrombosis 50, 51, 94, 95, 99, and discontinuation of DAPT in the weeks after stent implantation is one of the strongest risk factors for stent thrombosis, with the magnitude of risk and impact on mortality rate inversely proportional to the timing of occurrence after the procedure 145, 149, 150. Older observational studies found that the risk of stent-related thrombotic complications is highest in the first 4 to 6 weeks after stent implantation but continues to be elevated at least 1 year after DES placement 101, 102, 103, 149. Data from more recent large observational studies suggest that the time frame of increased risk of stent thrombosis is on the order of 6 months, irrespective of stent type (BMS or DES) 151, 152, 153. In a large cohort of patients from the Veterans Health Administration hospitals, the increased risk of surgery for the 6 months after stent placement was most pronounced in those patients in whom the indication for PCI was an MI (146). An additional consideration, irrespective of the timing of surgery, is that surgery is associated with proinflammatory and prothrombotic effects that may increase the risk of coronary thrombosis at the level of the stented vascular segment as well as throughout the coronary vasculature 154, 155.

Prior recommendations with regard to duration of DAPT 9, 104 and the timing of noncardiac surgery 15, 156 in patients treated with DES were based on observations of those treated with first-generation DES. Compared with first-generation DES, currently used newer-generation DES are associated with a lower risk of stent thrombosis and appear to require a shorter minimum duration of DAPT 17, 18, 21, 38, 96, 97 Several studies of DAPT duration in patients treated with newer-generation DES did not detect any difference in the risk of stent thrombosis between patients treated with 3 to 6 months of DAPT or patients treated with longer durations of DAPT (although these studies were underpowered to detect such differences) 17, 18, 19, 20, 21 (Data Supplement 1). Moreover, the safety of treating selected patients with newer-generation DES for shorter durations (3 or 6 months) of DAPT has been shown in a patient-level analysis pooling 4 trials evaluating DAPT durations (34). Furthermore, in the PARIS (Patterns of Nonadherence to Antiplatelet Regimens in Stented Patients) registry, interruption of DAPT according to physician judgment in patients undergoing surgery at any time point after PCI was not associated with an increased risk of MACE (145). On the basis of these considerations, the prior Class I recommendation that elective noncardiac surgery in patients treated with DES be delayed 1 year (15) has been modified to “optimally at least 6 months.” Similarly, the prior Class IIb recommendation that elective noncardiac surgery in patients treated with DES may be considered after 180 days (15) has been modified to “after 3 months.” Figure 6 summarizes recommendations on timing of elective noncardiac surgery in patients with coronary stents.
1-s2.0-S0735109716016995-gr6.jpg
 
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Less then 3 months post stent placement with sudden onset dyspnea. New dyspnea versus same at stent placement? If recent this guy needs a new echo showing no valvular disease or papillary muscle rupture, septal rupture, free wall rupture all complications post MI. We are focused on the stent and rethrombosis which is valid I too am concerned about post AMI anatomy. Good case for noninvasive continuous bo monitoring. Surgeon needs to document urgency. Likely Diastolic dysfunction with high lvedp whats his mitral valve look like now? Guy needs an echo with new dyspnea. If we followed guidelines for everything we would be ER doctors.
 
pgg said:
I don't mean to be rude, but if "usual hypotension" is a part of your inductions for elective surgery then you need to change the way you do inductions.

There is no reason for this patient's vitals to budge more than single digits in either direction peri-induction, a line or no a line.
Click to expand...

I applaud you for being a better anesthesiologist than myself. Despite what the cardiologist said, we all recognize that this guy is a high risk for stent thrombosis intraop. It's within reason to deliver a meticulous anesthetic, not only for the welfare of the patient but also to decrease your liability. If you are confident you can do that with a NIBP more power to you. I would feel more comfortable with an arterial line in this particular situation.
 
marr65 said:
I applaud you for being a better anesthesiologist than myself. Despite what the cardiologist said, we all recognize that this guy is a high risk for stent thrombosis intraop. It's within reason to deliver a meticulous anesthetic, not only for the welfare of the patient but also to decrease your liability. If you are confident you can do that with a NIBP more power to you. I would feel more comfortable with an arterial line in this particular situation.
Click to expand...


And it’s easier to place an Aline before CPR commences.
 
Does it really matter that during induction for most patients fluctuate 20-30%? For some like this one you need tight control. Remember too Pgg the bp is an estimate of systolic and diastolic pressure the only accurate value is mAp. With an aline the systolics and diastolic pressures are true measures assuming a ideal system. Nothing wrong with a aline here.
 
vector2 said:
The only way I'd do this case is if he had significant myelomalacia and the case was deemed surgically urgent or emergent. If not, send him to pain for an ESI and come back in 3 months. Just imagine if you ran into some bleeding and had to give products or surgeon requests TXA in a relatively fresh stent off DAPT.

Also, why is this guy short of breath with 1 flight of stairs? Limited mobility from pain or neuropathy I can understand, but I don't like the unexplained dyspnea.
Click to expand...

Hello, this is America. Most Americans get SOB going up a flight of stairs.
We like to eat and watch TV, not exercise. And this guy is almost 80 for crying out loud.
 
OP didn't say that the dyspnea was a new thing. However, this needs to be clarified. I am more concerned about the timing of this case than his SOB. Too damn soon. I wouldn't do it. I would ask if they cardiologist that cleared him to hold the DAPT and have surgery can come and get him safely through surgery and post op. Not me.
This is America. Land of lawsuit lotto. And if there was a poor outcome, I would feel crappy as well.
 
marr65 said:
Seriously, it's not for the EF of 72%, I want a normal BP during induction instead of the usual hypotension. If any one would look at my anesthetic, they can't blame the induction as a reason why this guy did poorly during the operation. All it takes is an extra 2-3 minutes to put one in while he is in holding area.
Click to expand...

The issue is stent thrombosis not coronary hypoperfusion. I put some CPB to sleep without a pre-induction A-line, but as FFP is saying, hypoperfusion isn't the issue here.
 
What I don't appreciate about the new guidelines is they don't offer any insight to continuing DAPT during surgery. Whereas their recommendations in the past had been "Continue DAPT at 6 months and proceed with surgery" now it's "Consider surgery after 3 months of DAPT". I understand the risk of bleeding always has to be weighed against the risk of thrombosis and they aren't the greatest folks to comment on that; however, I have yet to meet a surgeon willing to operate on DAPT even for a hernia.

There is no reason to do this case at this time, but more importantly this patient has been off his DAPT for 7 days and now gets to carry that increased risk without having his surgery done. Better than dying on the table or the floor post-op though.
 
marr65 said:
I applaud you for being a better anesthesiologist than myself. Despite what the cardiologist said, we all recognize that this guy is a high risk for stent thrombosis intraop. It's within reason to deliver a meticulous anesthetic, not only for the welfare of the patient but also to decrease your liability. If you are confident you can do that with a NIBP more power to you. I would feel more comfortable with an arterial line in this particular situation.
Click to expand...
That's fair. I just see people who routinely bottom out patients with their inductions because they give too much or are too impatient.

I would argue that if it's stent thrombosis you're worried about, it's the inflammatory nature of the surgery that is the risk, not perfusion pressure, and the need for exceptionally tight BP control is not critical.

It was the "usual hypotension" phrase in your post that caught my eye. 98% of post induction hypotension is avoidable and one doesn't have to be exceptional to avoid it. An a line is not unreasonable here. Hypotension is.
 
pgg said:
just see people who routinely bottom out patients with their inductions because they give too much or are too impatient.
Click to expand...
150 fent 200 prop tube, crank sevo to 2.2 ... bp cycles... ephedrine 5, 10,waiting for surgeon, ephedrine 10, 10.. start neo drip
Classic but inelegant induction protocol.
 
So it looks like the patient did not achieve maximum heart rate during the stress test and that's what Noyac was trying to convey.
So this is a patient who is symptomatic (SOB after one flight of stairs) and has a non conclusive stress test. I would not consider this guy optimized for surgery unless it is an emergency.
 
dhb said:
150 fent 200 prop tube, crank sevo to 2.2 ... bp cycles... ephedrine 5, 10,waiting for surgeon, ephedrine 10, 10.. start neo drip
Classic but inelegant induction protocol.
Click to expand...
I'm on the other end of the spectrum and it isn't always elegant. 50 fent 150 prop tube, sevo 1.5....bp cycles....baseline bp....feeling good, pt starts bucking with positioning. lol.... Should've checked twitches faster!
 
narcusprince said:
Does it really matter that during induction for most patients fluctuate 20-30%? For some like this one you need tight control. Remember too Pgg the bp is an estimate of systolic and diastolic pressure the only accurate value is mAp. With an aline the systolics and diastolic pressures are true measures assuming a ideal system. Nothing wrong with a aline here.
Click to expand...

But the systems aren't ideal and all you are still left with is really just the MAP.
 
Few thoughts;

Assuming DES, I’m amazed a cardiologist stopped DAPT in this post-MI patient.

If case is truly elective I think it’s a no go. I’d require documentation of risk for bad neurologic outcome at the least.

Stress echo that was close but not truly diagnostic 1mo ago.... I’d like to read the full echo report and know exactly what the cath findings were. Bedside TTE in holding bay if we are going forward, anything new and it’s “delayed”.

While I’d be confident/comfortable doing this case with PIV and NIBP, I think medicolegally I’d place an A-line. And if you’re placing one for “close/accurate hemodynamic monitoring” one could make the argument that induction is one of, if not the most likely period of hemodynamic fluctuation, so place pre-induction. I hate that oral board style answer but that’s the climate.
 
Why is this thread making a big deal over A-lines in a case that probably benefits from having one? Is it laziness or because some of you take too long to place them? It seems often on our board when Arterial line is suggested there’s a handful of people that shun its use.
 
Twiggidy said:
Why is this thread making a big deal over A-lines in a case that probably benefits from having one? Is it laziness or because some of you take too long to place them? It seems often on our board when Arterial line is suggested there’s a handful of people that shun its use.
Click to expand...
I had one colleague who always stated that there was no good evidence that arterial lines were superior in outcomes than NIBP. I didn't bother to prove him wrong, because if you have a case that needs it, then you place one.
 
One thing that bothers me is the mantra a normal ef= no heart failure. You can have a normal EF and have diastolic heart failure. I would place a preinduction arterial line and would not think twice about it.
 
I’ve never been impressed with the reliability of NIBP in hypotensive patients especially with irregular heartbeats. Ever get several cycles with no reading? It happens ALL THE TIME in my experience. I also throw an Aline in whenever the thought crosses my mind. Never had an instance when I regretted it.
 
Noyac said:
76yo M for L4/5-5/1 PSF with decompression.
Pt had MI with stent placement 3 months ago. Poor exercise tolerance, one flight of stairs SOB and leg cramping.
Stress Echo 2months this after stent and MI:
-no evidence of ischemia
-normal wall motion with EF 72%
-vitals during stress test 157/93 HR 116 max ( why does this matter and what does 20,000 value mean?)

Gupta-0.76

Cleared by cardiology

Plavix and ASA held 7days.

Pt is here for surgery at 7:30am.
Click to expand...
Pent, Sux, Tube
 
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