Another case to discuss

[Consigliere]

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So I couldn't care less

Finally. Finally someone who uses that phrase correctly. Please find all the "could care less, your vs. you're, and for all intensive purposes" mopes and school them. Oh....sage advice on the thread as well.

 

[Consigliere]

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.

Why? The head shaking implies you knew it was wrong. I thought you were a moral individual. Do you not have the patient's best interest at heart?

 

[vector2]

Your too wound up, consig. For all intensive purposes I could care less about finding all those mopes and schooling them.

 

[Consigliere]

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.

Sh_it girl, I got SOB reading this post.

 

[Consigliere]

Your too wound up, consig. For all intensive purposes I could care less about finding all those mopes and schooling them.

Nice!

 

[MoMoGesiologist]

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.

I don't think people are against a-lines. I think people just realize it's not therapeutic. If you have someone sick, dose your meds appropriately and cycle your NIBP if worried. It won't change what you do if you have an Aline or not.

For this patient, it doesn't sound like they will die on induction. They had their CAD stented and their echo was supposedly normal. It'll be in the middle of the case or after that they have a stent thrombosis. An Aline isn't going to prevent an MI. It'll maybe help you identify it 30 seconds earlier. The treatment is to go to cath lab. How is an Aline going to change your management? Also, if you are worried the patient is gonna have an intraop MI enough that you are putting in an Aline, why are you not worried enough to delay the case?

 

[Twiggidy]

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I don't think people are against a-lines. I think people just realize it's not therapeutic. If you have someone sick, dose your meds appropriately and cycle your NIBP if worried. It won't change what you do if you have an Aline or not.

For this patient, it doesn't sound like they will die on induction. They had their CAD stented and their echo was supposedly normal. It'll be in the middle of the case or after that they have a stent thrombosis. An Aline isn't going to prevent an MI. It'll maybe help you identify it 30 seconds earlier. The treatment is to go to cath lab. How is an Aline going to change your management? Also, if you are worried the patient is gonna have an intraop MI enough that you are putting in an Aline, why are you not worried enough to delay the case?

I'd rather see the pressure dip coming vs cycling a pressure that is 110/80, checking TheChive, and the 5 mins later the pressure is 60/20 (or it's not reading as was said above and I'm wondering what the pressure is) . In that five minutes I could've already been providing treatment to someone who may not be able to handle to much hypotension. Once the patient has decided to thrombose, what do you think during all the commotion of the slow code vs actual code would be the one monitor you wish you had (besides maybe a CVP).....probably an A-line, something you could've taken 10 mins at the beginning of the case to put in. I can also check gases, draw a HCT, etc in someone who we may want to know that info in if the case is long.

I totally understand that A-lines don't save lives but with patients who are on the edge, but somehow cleared, I don't want a song and dance with them in the OR. I want all my weapons as an anesthesiologist taking care of a sick patient cocked and loaded and ready to fire. TBH, A-lines are probably the compromise because if we really wanted to monitor for ischemia we'd drop a TEE but 90% of surgeons would freak out if they saw us do this.

 

[Noyac]

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%.

Bingo

 

[Noyac]

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.

And how long do you think he will have to be off DAPT after surgery as well?

 

[Noyac]

First of all, the ridiculousness of the A-line discussion here blows my mind.
If you want one then place it. I did and I placed it after induction.
If you don’t want one then fine. Let’s move on and stop posturing.

So to make some points here:
What concerns you and what will get you in trouble here?
Recent MI, The echo was Pretty good for my standards.
DES stent 3 months out. Recent rec’s discuss this and they seem to support going ahead.
What nobody has asked is, “where is the stent”? Does this matter?
What is the 20,000 number in reference to the stress test? What does it mean?
When is this guy most at risk if you do proceed with surgery?

Someone recommended sending him for ESI to bridge the time to surgery. I don’t disagree with this and this pt did have an ESI that helped for a couple days. But remember, he must stop DAPT for an ESI as well. So what’s the real benefit?

Now most of you are smarter than I am. What I’m also trying to present here is a discussion about the pressures to move forward and how we handle them. Many of you would not have done the case even with documentation of urgency and cards blessing. Maybe you are cautious or maybe you are smart as faack or maybe you are in a practice that doesn’t have the usual pressures that others have. Whatever the reason I think it is worth a discussion as to why you would take the stand you take. I did the case obviously. I didn’t have to do the case but I did. It was probably the most stable case I did all day. My healthy 65 yo anterior cervical fusion went asystolic in the next case for example (he did fine).

 

[vector2]

20,000 refers to the rate pressure product (HR * SBP) during stress echo. I dont remember the numbers so I'm guessing its gotta reach 20k or more for the test to have any worthwhile sensitivity.

Also good point about having to stop DAPT for the ESI. I wasnt even thinking about that.

 

[deleted162650]

My healthy 65 yo anterior cervical fusion went asystolic in the next case for example.

I don’t think you’re doin’ it right.

 

[deleted171991]

.

My healthy 65 yo anterior cervical fusion went asystolic in the next case for example (he did fine).

Must have been the tight eye-taping job by "anesthesia".

 

[Tramadeezy]

Pain doc here. Not totally relevant to topic but many interventional guys (myself included) would do transformational ESI even if on DAPT. Especially if it helped keep him out of OR. After risks/benefits discussion of course 🙂

First of all, the ridiculousness of the A-line discussion here blows my mind.
If you want one then place it. I did and I placed it after induction.
If you don’t want one then fine. Let’s move on and stop posturing.

So to make some points here:
What concerns you and what will get you in trouble here?
Recent MI, The echo was Pretty good for my standards.
DES stent 3 months out. Recent rec’s discuss this and they seem to support going ahead.
What nobody has asked is, “where is the stent”? Does this matter?
What is the 20,000 number in reference to the stress test? What does it mean?
When is this guy most at risk if you do proceed with surgery?

Someone recommended sending him for ESI to bridge the time to surgery. I don’t disagree with this and this pt did have an ESI that helped for a couple days. But remember, he must stop DAPT for an ESI as well. So what’s the real benefit?

Now most of you are smarter than I am. What I’m also trying to present here is a discussion about the pressures to move forward and how we handle them. Many of you would not have done the case even with documentation of urgency and cards blessing. Maybe you are cautious or maybe you are smart as faack or maybe you are in a practice that doesn’t have the usual pressures that others have. Whatever the reason I think it is worth a discussion as to why you would take the stand you take. I did the case obviously. I didn’t have to do the case but I did. It was probably the most stable case I did all day. My healthy 65 yo anterior cervical fusion went asystolic in the next case for example (he did fine).

 

[KaoticMessiah]

I had a case like this last year.
70ish guy for TURP. Active, in [relatively] good shape and able to achieve > 7 METs, but history of severe CAD with a recent DES placement 3 months prior to surgery. Want to say he had two stents put in, one in Cx and other in mid-RCA, something like that. Wasn't a proximal left main or anything, but still some significant disease.
Anywho, Cardiologist had given that patient "clearance" to proceed with this entirely elective procedure off DAPT. No rationale as to why in the note. Tried to contact the office to see if there was something I was missing, didn't receive any call back. He hadn't achieved great TIMI flow after deploying one of the stents, so I thought "well maybe the Cardiologist is figuring an in-stent thrombosis in a person with good collaterals and already not great post-stent flow wouldn't be catastrophic." But I didn't have the chance to talk it through with him because he never called back.
I ended up canceling the case after a long discussion with the patient about the very real risk of an in-stent thrombosis leading to significant cardiac issues. He was reasonable and agreed that it should probably be delayed for a year, and that he could absolutely live with the lifestyle disturbances that BPH had caused him.
The surgeon then came to the bedside, and said something to the effect of "Well I don't agree with the cancelation, the Cardiologist deals with this stuff all the time and you don't, so I don't know why I should trust your judgement over the Cardiologist's." Right in front of the patient.
I'm not a confrontational guy so I just basically said that while I'm sure he's a fine cardiologist, I don't agree with his decision in this situation.

I ended up taking care of the same patient 8 months later after the full 12 months had passed. He remembered me and was grateful for the care I gave him both times. He ended up doing just fine, did not die under my watch.

Some of my colleagues made the argument that, well you've already subjected him to the risk of being off DAPT for 7 days, might as well do the case since he's gone through all that trouble. My argument is that while yes, they've had some risk while off DAPT, if you put them through the pro-inflammatory, pro-thrombotic state that comes after surgery, you're greatly increasing their risk unnecessarily.

Just some ramblings from a young attending trying to navigate the murky waters

 

[Robotic Wis-Hipple]

I don’t know, I think the a-line convo is interesting here. I work in a culture/setting where we get **** for placing them because it may cost the surgeon 3-5min. So this is a real issue we fight almost daily. But outside of that how many of us are placing a-lines for a posterior spinal fusion in a 70yo? These cases are a dime a dozen. I typically don’t.

So, if something is making me think I need one, and it’s the fact that it’s due to the patient’s recent cardiac history it follows that maybe this dude isn’t optimized for an elective procedure. So then it’s sort of like arguing that we can do cases we typically shouldn’t by just increasing the level of monitoring, and if that’s the case, why cancel anything?

Full disclosure, in my shop probably 90% of attendings do this case with minimal pushback multiple times per year (and I’d be one of them), but again, culture here isn’t exactly weighted towards Anesthesia. From what we know and what’s implied about this case I have little doubt we all get him through this case without issue, it’s not the intraop period that concerns me, it’s the fact that it’s pretty clear he’s at increased risk periop, and for what?

 

[MoMoGesiologist]

What's the liability for the anesthesiologist if a patient has an adverse cardiac event despite clearance from cardiology? What if it's an inappropriate clearance and you still proceed with the case (such as clearing the patient to be off DAPT for an elective surgery too soon after stent placement)?

If the cardiologist accepts responsibility for cardiac clearance, then why not just proceed with all cases we may not feel comfortable with from a cardiac standpoint? "The heart doctors the expert and told me it was fine!"

 

[Maverikk]

Aline: if you even have an inkling you need an aline then do one, this case could go either way. Provided you're smooth and can do one in less than 10min after meeting the patient

The case: interesting and brings up good points. I'd do it with an aline, document the heck out of it, you can't change surgeon/consults minds about the best planning. The interesting part which was brought up: how do you convey your opinions about case?... I'd do the regular workup and tell him about the risks and get an idea of how elective/urgent this was

 

[Mman]

I don’t know, I think the a-line convo is interesting here. I work in a culture/setting where we get **** for placing them because it may cost the surgeon 3-5min. So this is a real issue we fight almost daily. But outside of that how many of us are placing a-lines for a posterior spinal fusion in a 70yo? These cases are a dime a dozen. I typically don’t.

I'd say the vast majority of multi level spine fusions get arterial lines from us, especially the geriatric population. A few young healthy ones don't, but that's not who we are usually doing these cases on. Then again some of that is surgeon dependent and there is a big difference between a 90 minute case with 100 ml EBL and a 4 hour case with 500+ EBL.

 

[GravelRider]

Most of the cardiology “clearances” I see lately do not say “cleared for surgery” (justifiably so). Most notes say something along the lines of “intermediate risk for intermediate surgery.” The problem is most surgeons see the cardiology note and assume everything is good to go.

The problem I see here is that these cases come to the attention of the anesthesiologist 15 minutes before the scheduled start. Now you are expected to dig through this guy’s history and properly risk stratify him while the OR clock is ticking. At the very least this should have been brought to the anesthesiology department’s attention the day before. A proper conversation between the cardiologist, anesthesiologist, and surgeon is what is needed here to both determine the real urgency for the procedure and the patient’s perioperative risk. We can all get this patient through the surgery (a-line or no a-line) pretty easily. However, his increased risk does not stop the moment he hits pacu and you run off to see your next patient. This patient probably should have had this surgery postponed, but the morning of the procedure is the wrong time to do it. It’s hard to stop a moving train. The surgeon is less pissed off when a case is cancelled a week before rather than the day of (again, justifiably so).

I would have begrudgingly done the procedure (without an a-line), but explained in full detail all of his increased cardiac risks.

 

[Noyac]

.
Must have been the tight eye-taping job by "anesthesia".

Aggressive retraction on the carotid. Two full screens before a beat occurred. No meds required to treat it though.

 

[Noyac]

Most of the cardiology “clearances” I see lately do not say “cleared for surgery” (justifiably so). Most notes say something along the lines of “intermediate risk for intermediate surgery.” The problem is most surgeons see the cardiology note and assume everything is good to go.

The problem I see here is that these cases come to the attention of the anesthesiologist 15 minutes before the scheduled start. Now you are expected to dig through this guy’s history and properly risk stratify him while the OR clock is ticking. At the very least this should have been brought to the anesthesiology department’s attention the day before. A proper conversation between the cardiologist, anesthesiologist, and surgeon is what is needed here to both determine the real urgency for the procedure and the patient’s perioperative risk. We can all get this patient through the surgery (a-line or no a-line) pretty easily. However, his increased risk does not stop the moment he hits pacu and you run off to see your next patient. This patient probably should have had this surgery postponed, but the morning of the procedure is the wrong time to do it. It’s hard to stop a moving train. The surgeon is less pissed off when a case is cancelled a week before rather than the day of (again, justifiably so).

I would have begrudgingly done the procedure (without an a-line), but explained in full detail all of his increased cardiac risks.

This is exactly where I was going to take this thread if someone had not brought it up after the “fit for surgery” part of the discussion.

We have a periop clinic which is run by the hospitalists because they needed more RVU’s to justify adding staff and we didn’t. This was fine by my group because we didn’t want to sit in a clinic. That’s not why I went into anesthesia. I know some of you will take issue with this. But we made it clear that we needed complete involvement and that we were the final word on if a case went to the OR or not. Things were going pretty well with the hospitalists staffing the clinic and they enjoyed getting off the floor from time to time. Then at some point last year they decided to hire a NP to staff the clinic with physician backup. This has been an eye opening experience for all of us. The NP is good at collecting data and putting together a note. But she has zero understanding. This case should have been seen by an anesthesiologist before surgery, period. To put this on my plate at 7am on a Monday is an impossible task. It is a setup for failure and confrontation. And the fact that we get these pts through their surgery without any issues just makes it worse.

 

[Psai]

This is exactly where I was going to take this thread if someone had not brought it up after the “fit for surgery” part of the discussion.

We have a periop clinic which is run by the hospitalists because they needed more RVU’s to justify adding staff and we didn’t. This was fine by my group because we didn’t want to sit in a clinic. That’s not why I went into anesthesia. I know some of you will take issue with this. But we made it clear that we needed complete involvement and that we were the final word on if a case went to the OR or not. Things were going pretty well with the hospitalists staffing the clinic and they enjoyed getting off the floor from time to time. Then at some point last year they decided to hire a NP to staff the clinic with physician backup. This has been an eye opening experience for all of us. The NP is good at collecting data and putting together a note. But she has zero understanding. This case should have been seen by an anesthesiologist before surgery, period. To put this on my plate at 7am on a Monday is an impossible task. It is a setup for failure and confrontation. And the fact that we get these pts through their surgery without any issues just makes it worse.

Even with carefully created guidelines and protocols, there is little use in having an np in a preop clinic. There are many times they don't get the information that you need and their lack of medical knowledge is very apparent.

 

[Robotic Wis-Hipple]

This is exactly where I was going to take this thread if someone had not brought it up after the “fit for surgery” part of the discussion.

We have a periop clinic which is run by the hospitalists because they needed more RVU’s to justify adding staff and we didn’t. This was fine by my group because we didn’t want to sit in a clinic. That’s not why I went into anesthesia. I know some of you will take issue with this. But we made it clear that we needed complete involvement and that we were the final word on if a case went to the OR or not. Things were going pretty well with the hospitalists staffing the clinic and they enjoyed getting off the floor from time to time. Then at some point last year they decided to hire a NP to staff the clinic with physician backup. This has been an eye opening experience for all of us. The NP is good at collecting data and putting together a note. But she has zero understanding. This case should have been seen by an anesthesiologist before surgery, period. To put this on my plate at 7am on a Monday is an impossible task. It is a setup for failure and confrontation. And the fact that we get these pts through their surgery without any issues just makes it worse.

Our preop clinic is essentially NP run as well with one physician director that is supposedly signing off on things that need it, but this exact situation comes up for the same reasons.

I actually think Physicians that have never been in an OR have a hard time understanding the gravity. I mean a cardiologist saying “0.7324675% risk” based on some risk model that is clearly incomplete, or saying “avoid hypotension/tachycardia” just shows they both completely underestimate our own intelligence/knowledge and have no clue how volatile/labile some procedures can be.

I mean half of my ICU dropoffs are into units primarily staffed by NPs/PAs that look at me like I have 3 heads when I try to explain at what BP the RV stops looking happy etc. It’s a problem with context, and most providers in general have no experience in our theater.

But yes, this case will continue to show up in our preop holding areas at 0600 making it near impossible to cancel day of unless we take control of the preop clinics in a more regimented way.

 

[IMGASMD]

It is a setup for failure and confrontation. And the fact that we get these pts through their surgery without any issues just makes it worse.

Did you (guys) do anything about it? I think even your run of the mill hospitalist will not get “it”. One of my critiques regarding PSH is that no one will pay for anesthesiologists to be in PAT. But most people who are willing to be in clinic don’t have enough knowledge or advice understanding of anesthesia to give any meaningful recommendations.

I usually also ask them to go back to their own primary care physicians, “we are meeting for the first time, your own physicians know you much better than I do...” to mitigate some risks for me and the patient. But I also understand that’s not always possible.

Also for this case, as per OP’s discussion, it was seen by a NP, was s/he following the guideline regarding waiting period after stent placement? Was that brought up with the IM group seeing PAT?

 

[GravelRider]

The problem with these preop clinics run by NPs is that all they are really doing is checking a box that a medical or cardiology clearance is present in the chart. They are not digging through the information nor do they have the proper knowledge to make decisions based on that information. To make these preop clinics even remotely efficient and prevent “day-of” surgery cancellations, anesthesiology has to be somewhat involved. It could be something as simple as making a reasonably broad statement like all patients with an MI, stroke, or cardiac intervention within the past year must be brought to the attention of the anesthesiology department before the day of surgery.

 

[Twiggidy]

t is a setup for failure and confrontation. And the fact that we get these pts through their surgery without any issues just makes it worse.

This is the entire situation right here and trust me I'm on your side on this one. This is my daily life with my service. We tow the line with these vulnerable patients and the surgeons see us accomplish the task therefore they think they can push any patient with a half arse workup through any case. People can scoff all they want at the idea of "pressure from surgeons" but it's a real thing when you become know as "the case canceller" and the suddenly surgeons are requesting other anesthesiologists for patients you could otherwise handle. That's food off your plate.

What's the liability for the anesthesiologist if a patient has an adverse cardiac event despite clearance from cardiology? What if it's an inappropriate clearance and you still proceed with the case (such as clearing the patient to be off DAPT for an elective surgery too soon after stent placement)?

If the cardiologist accepts responsibility for cardiac clearance, then why not just proceed with all cases we may not feel comfortable with from a cardiac standpoint? "The heart doctors the expert and told me it was fine!"

I think this is a good point of discussion and it may have been addressed elsewhere on this forum. I was always taught in residency that no matter what the medicine doc or cardiologists writes, WE are the final clearance. The cardiologist isn't the one giving the anesthetic. No one is taking the medicine doc or cardiologist to court for an intraop complication.

 

[NightNight]

Most of the cardiology “clearances” I see lately do not say “cleared for surgery” (justifiably so). Most notes say something along the lines of “intermediate risk for intermediate surgery.” The problem is most surgeons see the cardiology note and assume everything is good to go.

The problem I see here is that these cases come to the attention of the anesthesiologist 15 minutes before the scheduled start. Now you are expected to dig through this guy’s history and properly risk stratify him while the OR clock is ticking. At the very least this should have been brought to the anesthesiology department’s attention the day before. A proper conversation between the cardiologist, anesthesiologist, and surgeon is what is needed here to both determine the real urgency for the procedure and the patient’s perioperative risk. We can all get this patient through the surgery (a-line or no a-line) pretty easily. However, his increased risk does not stop the moment he hits pacu and you run off to see your next patient. This patient probably should have had this surgery postponed, but the morning of the procedure is the wrong time to do it. It’s hard to stop a moving train. The surgeon is less pissed off when a case is cancelled a week before rather than the day of (again, justifiably so).

I would have begrudgingly done the procedure (without an a-line), but explained in full detail all of his increased cardiac risks.

This. Sometimes the best way to get a case cancelled is to scare the **** out of the patient (or their family).

 

[anbuitachi]

Thats one of the problems. It's not that we get thru these cases without anything bad happening that the surgeon thinks it's no big deal, it's probably more due to the fact that many anesthesiologists wouldnt even cancel this case because they think they can get thru it with no problems. The problem is when a chunk of us proceeds, the surgeon then expect these cases to go, because why would 1 group proceed and another bunch of anesthesiologists cancel? Personally I think if we are putting patient safety first, and not how quickly the surgeon can get out of the hospital at the end of the day, or the size of your wallet, then elective cases in this type of patients should be cancelled. I know it may be hard if the anesthesiology group doesn't have a strong presence/backing, and the anesthesiologists may not want to upset the surgeon, or be known as the guy who cancels , but this is the patients life we are talking about and it's pretty sad if we as a profession is reduced to making decisions based on how it affects the surgeons mood and not the benefit of the patient. no wonder so many surgeons think lowly of our profession even though we are both doctors.

I dont even think DAPT is such a complicated issue if the case is purely elective. There are published guidelines that you can just shove in the surgeons face. Straight from American college of cardiology:

"In patients with acute coronary syndrome (ACS) (non-ST elevation [NSTE]-ACS or ST elevation myocardial infarction [STEMI]) treated with DAPT after BMS or DES implantation, P2Y12 inhibitor therapy (clopidogrel, prasugrel, or ticagrelor) should be given for at least 12 months (Class I)."

This patient had MI, had stent, therefore DAPT should not be stopped for 12 months. It's class 1 recommendation.


I might be spoiled since im at a large institution so the department has policies on these types of patients but this case wouldve been cancelled (unless theres a urgent reason to do it).

 

[caligas]

So for bare metal one month is ok but 6 months is better?

 

[anbuitachi]

So for bare metal one month is ok but 6 months is better?

Depends on what OK means to you

In patients with acute coronary syndrome (ACS) (non-ST elevation [NSTE]-ACS or ST elevation myocardial infarction [STEMI]) treated with DAPT after BMS or DES implantation, P2Y12 inhibitor therapy (clopidogrel, prasugrel, or ticagrelor) should be given for at least 12 months (Class I)."

DAPT should not be stopped in either DES or BMS for 12 months

 

[Mman]

DAPT should not be stopped in either DES or BMS for 12 months

From ACC guidelines regarding antiplatelet therapy...

CLASS I 1. In patients undergoing urgent noncardiac surgery during the first 4 to 6 weeks after BMS or DES implantation, DAPT should be continued unless the relative risk of bleeding outweighs the benefit of the prevention of stent thrombosis. (Level of Evidence: C) 2. In patients who have received coronary stents and must undergo surgical procedures that mandate the discontinuation of P2Y12 platelet receptor–inhibitor therapy, it is recommended that aspirin be continued if possible and the P2Y12 platelet receptor–inhibitor be restarted as soon as possible after surgery. (Level of Evidence: C) 3. Management of the perioperative antiplatelet therapy should be determined by a consensus of the surgeon, anesthesiologist, cardiologist, and patient, who should weigh the relative risk of bleeding with that of stent thrombosis. (Level of Evidence: C)

So yes, you can come off your DAPT in less than 12 months. It just depends on the surgery and the relative degree of urgency for doing it (and yes it is a class I recommendation)

 

[caligas]

Depends on what OK means to you

In patients with acute coronary syndrome (ACS) (non-ST elevation [NSTE]-ACS or ST elevation myocardial infarction [STEMI]) treated with DAPT after BMS or DES implantation, P2Y12 inhibitor therapy (clopidogrel, prasugrel, or ticagrelor) should be given for at least 12 months (Class I)."

DAPT should not be stopped in either DES or BMS for 12 months

I mean for non MI patient.

 

[Southpaw]

Just because you get a patient through the surgery doesn’t make it okay. Complications in surgery and anesthesia, especially in the OR, are rare. Taking a patient off DAPT 3 months after a stent (regardless of location) is dicey business. The in-stent thrombosis could occur days to weeks after and be related to the inflammatory cycle started by surgery. Keep the patient on ASA. I don’t know any pain docs that take patients off of ASA for an ESI. I certainly don’t care about ASA when I place an epidural or spinal.

I also wished that I encountered more thoughtful surgeons with regard to this issue. I shouldn’t find out about this patient DOS. Honestly that in itself warrants delaying the case, after a frank discussion with the patient.

Anyway, everyone here is a cowboy (push forward! No aline needed!). Personally, on this one, I hit the brakes after explaining to the patient my reasoning and backing it with some evidence. If their surgeon can’t operate on ASA, then perhaps they need another surgeon. One who actually cares about the heart and the potential damage induced by in-stent thrombosis.

 

[Ronin786]

From ACC guidelines regarding antiplatelet therapy...

CLASS I 1. In patients undergoing urgent noncardiac surgery during the first 4 to 6 weeks after BMS or DES implantation, DAPT should be continued unless the relative risk of bleeding outweighs the benefit of the prevention of stent thrombosis. (Level of Evidence: C) 2. In patients who have received coronary stents and must undergo surgical procedures that mandate the discontinuation of P2Y12 platelet receptor–inhibitor therapy, it is recommended that aspirin be continued if possible and the P2Y12 platelet receptor–inhibitor be restarted as soon as possible after surgery. (Level of Evidence: C) 3. Management of the perioperative antiplatelet therapy should be determined by a consensus of the surgeon, anesthesiologist, cardiologist, and patient, who should weigh the relative risk of bleeding with that of stent thrombosis. (Level of Evidence: C)

So yes, you can come off your DAPT in less than 12 months. It just depends on the surgery and the relative degree of urgency for doing it (and yes it is a class I recommendation)

The new guidelines are terribly confusing. They differentiate between patients with ACS and stable ischemic heart disease. Which given the frequency of cardiologists stenting folks left and right, can be fairly blurry. What you're referencing is the duration after any sort of DES. There are different guidelines for patients undergoing elective surgery. This chart sums it up.

 

[Mman]

There are different guidelines for patients undergoing elective surgery.

As I said, for surgeries that aren't purely elective it is different.

 

[Ronin786]

As I said, for surgeries that aren't purely elective it is different.

Sorry I meant to reply to @anbuitachi

 

[coffeebythelake]

On a related note, tell me what you think about this. This was a case I took care of about 1 1/2 years ago.

Elderly female with DES placed 2 months ago, now asymptomatic from cardiac standpoint, going for ERCP with stenting due to obstructive jaundice due to cholangiocarcinoma. Was already taken off plavix x8 days, but kept on ASA. The anesthesiologist the day before cancelled the case pending cardiologist evaluation. Well cardiology never saw thr patient even after 24 hours, and after discussion with GI doc and patient I proceeded with the case. My rationale was multi fold:

1. Pt already off plavix and every hour we wait the higher the risk to this patient. They need to be back on DAPT asap.

2. This is endoscopic case which I expect minimal stress and inflammatory response

3. This was not elective and patient cannot wait until 6 months. Her life expectancy was likely less than that, and this was done under the name of palliative care

Thoughts

 

[IMGASMD]

On a related note, tell me what you think about this. This was a case I took care of about 1 1/2 years ago.

Elderly female with DES placed 2 months ago, now asymptomatic from cardiac standpoint, going for ERCP with stenting due to obstructive jaundice due to cholangiocarcinoma. Was already taken off plavix x8 days, but kept on ASA. The anesthesiologist the day before cancelled the case pending cardiologist evaluation. Well cardiology never saw thr patient even after 24 hours, and after discussion with GI doc and patient I proceeded with the case. My rationale was multi fold:

1. Pt already off plavix and every hour we wait the higher the risk to this patient. They need to be back on DAPT asap.

2. This is endoscopic case which I expect minimal stress and inflammatory response

3. This was not elective and patient cannot wait until 6 months. Her life expectancy was likely less than that, and this was done under the name of palliative care

Thoughts

I would proceed. Have a goal of care discussion with patient and family. Have a code status discussion with everyone.


1. I’m the most junior member of the anesthesia department. If my senior don’t want to do it, doubt it will fall on anyone else.
2. It is a palliative case, patient likely won’t have another 10 months to wait. Is this asa 4? If it is, more reason to do it.
3. What is waiting for cardiology going to change my/their management? Will they put another stent? Obviously CABG is out of running.

 

[Arch Guillotti]

On a related note, tell me what you think about this. This was a case I took care of about 1 1/2 years ago.

Elderly female with DES placed 2 months ago, now asymptomatic from cardiac standpoint, going for ERCP with stenting due to obstructive jaundice due to cholangiocarcinoma. Was already taken off plavix x8 days, but kept on ASA. The anesthesiologist the day before cancelled the case pending cardiologist evaluation. Well cardiology never saw thr patient even after 24 hours, and after discussion with GI doc and patient I proceeded with the case. My rationale was multi fold:

1. Pt already off plavix and every hour we wait the higher the risk to this patient. They need to be back on DAPT asap.

2. This is endoscopic case which I expect minimal stress and inflammatory response

3. This was not elective and patient cannot wait until 6 months. Her life expectancy was likely less than that, and this was done under the name of palliative care

Thoughts

Somebody should talk to the guy who cancelled the case.

 

[GaseousClay]

Somebody should talk to the guy who cancelled the case.

sounds like academic or kaiser model of a doc kicking the can down the road for the next guy to deal with

 

[IMGASMD]

sounds like academic or kaiser model of a doc kicking the can down the road for the next guy to deal with

Or any places that doesn’t really reward productivity....

 

[coffeebythelake]

sounds like academic or kaiser model of a doc kicking the can down the road for the next guy to deal with

Ding ding ding

 

[anbuitachi]

Sorry I meant to reply to @anbuitachi

I don't remember the question but I only stated MI since this patient had MI. But Yea it's different

On a related note, tell me what you think about this. This was a case I took care of about 1 1/2 years ago.

Elderly female with DES placed 2 months ago, now asymptomatic from cardiac standpoint, going for ERCP with stenting due to obstructive jaundice due to cholangiocarcinoma. Was already taken off plavix x8 days, but kept on ASA. The anesthesiologist the day before cancelled the case pending cardiologist evaluation. Well cardiology never saw thr patient even after 24 hours, and after discussion with GI doc and patient I proceeded with the case. My rationale was multi fold:

1. Pt already off plavix and every hour we wait the higher the risk to this patient. They need to be back on DAPT asap.

2. This is endoscopic case which I expect minimal stress and inflammatory response

3. This was not elective and patient cannot wait until 6 months. Her life expectancy was likely less than that, and this was done under the name of palliative care

Thoughts

Would you even take this patient off plavix if patient didn't already have it off? I don't see why it can't be done with DAPT.

 

[coffeebythelake]

Would you even take this patient off plavix if patient didn't already have it off? I don't see why it can't be done with DAPT.

Good question. I don't know the bleeding risk with this particular procedure if on DAPT.
Is risk of bleeding and its complications so great that they would subject a patient to the risk of in-stent thrombosis?
In my experience lots of the GI docs out there aren't interested in looking at the whole picture
I'm sure this was not a discussion the GI doc had with the patient

 

[Noyac]

Good question. I don't know the bleeding risk with this particular procedure if on DAPT.
Is risk of bleeding and its complications so great that they would subject a patient to the risk of in-stent thrombosis?
In my experience lots of the GI docs out there aren't interested in looking at the whole picture
I'm sure this was not a discussion the GI doc had with the patient

Bleeding risk can be minimal to mild. If they do a papulotomy, it will bleed. The question now becomes, who cares? It’s in the small intestine and therefore won’t cause Great concern 7ntil it continues for 3 days or so. Not your issue. If they want to practice as uneducated technicians then who am I to stop them?

 

[sigrhoillusion]

So the risk in all of this is re-thrombosis. Let's say this guy SHOULD HAVE stayed on his DAPT, but now is off for 7 days. What is the increased risk of thrombosis of now doing the surgery with anesthesia versus him not being on his DAPT alone? Is it a two-hit hypothesis model where you need both to occur, or is the cat already out of the bag and this guy is already on his road to a clot? At what point do you proceed? I wonder cause we had a guy last month who was getting a purely elective procedure done 6 months after DES placement. (From my memory, I'm pretty sure it was placed for CAD and not for ACS/MI) Cardiology note stated that he was cleared for surgery but he should continue DAPT for procedure. Of course day of surgery at 630am patient states he stopped DAPT for a week because ortho office told him to.

My questions were, why did this guy still need to be on DAPT 6 months after DES. Did he really need to be on them? Why did cards say to continue them? And if he did need to continue them and now that he's stopped, what should we do? Of course no cardiology office is open that early. We ended up postponing the case until we got more details from cards. Ortho got a hold of the office at some point but not sure if they plavix loaded him or not... Ended up moving up an inpatient and only delayed the room by a a few minutes. From a medical standpoint I think it was perfectly fine to proceed, but the fact that the cards consult said one thing and the patient did another and it was an elective case, there wasn't a real reason to push to go. I of course told the patient that our concerns were about possible thrombosis and his daughter was there and she was having NO qualms with postponing if there was any chance he was at increased risk for anything.

On another note, in response to the a-line, I'd probably have placed one.

 

[anbuitachi]

So the risk in all of this is re-thrombosis. Let's say this guy SHOULD HAVE stayed on his DAPT, but now is off for 7 days. What is the increased risk of thrombosis of now doing the surgery with anesthesia versus him not being on his DAPT alone? Is it a two-hit hypothesis model where you need both to occur, or is the cat already out of the bag and this guy is already on his road to a clot? At what point do you proceed? I wonder cause we had a guy last month who was getting a purely elective procedure done 6 months after DES placement. (From my memory, I'm pretty sure it was placed for CAD and not for ACS/MI) Cardiology note stated that he was cleared for surgery but he should continue DAPT for procedure. Of course day of surgery at 630am patient states he stopped DAPT for a week because ortho office told him to.

My questions were, why did this guy still need to be on DAPT 6 months after DES. Did he really need to be on them? Why did cards say to continue them? And if he did need to continue them and now that he's stopped, what should we do? Of course no cardiology office is open that early. We ended up postponing the case until we got more details from cards. Ortho got a hold of the office at some point but not sure if they plavix loaded him or not... Ended up moving up an inpatient and only delayed the room by a a few minutes. From a medical standpoint I think it was perfectly fine to proceed, but the fact that the cards consult said one thing and the patient did another and it was an elective case, there wasn't a real reason to push to go. I of course told the patient that our concerns were about possible thrombosis and his daughter was there and she was having NO qualms with postponing if there was any chance he was at increased risk for anything.

On another note, in response to the a-line, I'd probably have placed one.

Depends on overall picture. It's a class 2b recommendation to co tinue dapt over 6 months. So if the patient has 13 stents with last one placed 6 months ago, and the Ortho procedure is a 10 min finger procedure, it's reasonable to keep it on

 

[Noyac]

So the risk in all of this is re-thrombosis. Let's say this guy SHOULD HAVE stayed on his DAPT, but now is off for 7 days. What is the increased risk of thrombosis of now doing the surgery with anesthesia versus him not being on his DAPT alone? Is it a two-hit hypothesis model where you need both to occur, or is the cat already out of the bag and this guy is already on his road to a clot? At what point do you proceed? I wonder cause we had a guy last month who was getting a purely elective procedure done 6 months after DES placement. (From my memory, I'm pretty sure it was placed for CAD and not for ACS/MI) Cardiology note stated that he was cleared for surgery but he should continue DAPT for procedure. Of course day of surgery at 630am patient states he stopped DAPT for a week because ortho office told him to.
/QUOTE]
This is how I look at this case. He was off the DAPT for 7 days already. But we haven’t insulted him with surgery making him hypercoaguable, yet. And if we proceed, he will remain off DAPT for another 10 days (lumbar fusion). These two things really step up the risk in my opinion.

Nobody has asked where the stent is. It’s in the circumflex. Does this matter?

 

[Robotic Wis-Hipple]

So the risk in all of this is re-thrombosis. Let's say this guy SHOULD HAVE stayed on his DAPT, but now is off for 7 days. What is the increased risk of thrombosis of now doing the surgery with anesthesia versus him not being on his DAPT alone? Is it a two-hit hypothesis model where you need both to occur, or is the cat already out of the bag and this guy is already on his road to a clot? At what point do you proceed? I wonder cause we had a guy last month who was getting a purely elective procedure done 6 months after DES placement. (From my memory, I'm pretty sure it was placed for CAD and not for ACS/MI) Cardiology note stated that he was cleared for surgery but he should continue DAPT for procedure. Of course day of surgery at 630am patient states he stopped DAPT for a week because ortho office told him to.

My questions were, why did this guy still need to be on DAPT 6 months after DES. Did he really need to be on them? Why did cards say to continue them? And if he did need to continue them and now that he's stopped, what should we do? Of course no cardiology office is open that early. We ended up postponing the case until we got more details from cards. Ortho got a hold of the office at some point but not sure if they plavix loaded him or not... Ended up moving up an inpatient and only delayed the room by a a few minutes. From a medical standpoint I think it was perfectly fine to proceed, but the fact that the cards consult said one thing and the patient did another and it was an elective case, there wasn't a real reason to push to go. I of course told the patient that our concerns were about possible thrombosis and his daughter was there and she was having NO qualms with postponing if there was any chance he was at increased risk for anything.

On another note, in response to the a-line, I'd probably have placed one.

Stopping DAPT incurs a risk by itself, but there is certainly increased risk from surgery in addition to that risk due to the known inflammatory response that is stimulated by surgical insult.