Case question

[badgas]

Newbie here on anesthesia rotation... starting CA1 in a couple months. I saw a case today that was not all that interesting, but the decision making was. 60 y/o M in for an elective b/l mastectomy for "idiopathic" gynecomastia. PMH of DM, Etoh abuse (still drinks a 12 pack/day), HTN, CAD and chronic renal failure. No DOCUMENTED hx of hep C, cirrhosis, or liver problems. His only labs are a BMP showing BUN 66, Cr 3.4 and a normal H&H. No coags, LFTs, no platelet count. When asked if he's had any bleeding problems in the past, he said that he did back in December when a dialysis cath was placed and he needed a "bunch" of blood transfusions. CRNA calls surgeon to ask if pt/INR is needed. Surgeon says no and they will proceed as scheduled. I ask the attending anesthesiologist what should be done, and he informs me that as long as the surgeon was informed of things, then you are safe. To make things more complicated, we are at the VA where STAT lab means sometime before next month.

Now I know that there are several questionable things going on here. Obviously the INR doesn't mean jack since he's not on coumadin and they need a pt/ptt. They also need to get a platelet count. This guy has gynecomastia/alcoholism/previous bleeding problems and it appears that no one has even considered that he has some liver failure going on. You can't only blame the CRNA for not putting the gynecomastia and etoh use together with the probability that this guy has serious liver dz and will bleed like a stuck pig... because the surgeon did not either! My question is what I should do in the future as a resident in a situation like that. How about as an attending? Can I completely refuse to do the ELECTIVE case? From a legal standpoint, I was told that I would be safe since the surgeon was informed. But I would think that it would be my responsibility to protect the patient from stupid decisions regardless of who is legally responsible. I don't want my name ending up on a lawsuit even if it gets dropped. More importantly, I don't want a patient bleeding out on the table. Any thoughts??

 

[Planktonmd]

Obviously the INR doesn't mean jack since he's not on coumadin and they need a pt/ptt.

So if someone is not on Coumadin the INR is useless?
What do you expect would happen to the INR in advanced liver disease?
Is it possible to have an elevated PT and a normal INR?

Now, about the response from the anesthesiologist: " if you tell the surgeon then you are protected", this is absolutely incorrect (even in the VA)!
If this guy is going to have surgery by a surgeon that can turn any surgery into a blood bath I would definitely agree with you and request to know the coagulation status and the CBC.
On the other hand if I am dealing with a surgeon that I know well and I know that we are going to be done with this bilateral male mastectomy in 45 minutes with minimal blood loss, I would proceed with the available data provided there is nothing too alarming in his cardiac history.

 

[urge]

My question is what I should do in the future as a resident in a situation like that. How about as an attending? Can I completely refuse to do the ELECTIVE case? From a legal standpoint, I was told that I would be safe since the surgeon was informed. But I would think that it would be my responsibility to protect the patient from stupid decisions regardless of who is legally responsible. I don't want my name ending up on a lawsuit even if it gets dropped. More importantly, I don't want a patient bleeding out on the table. Any thoughts??

You seem to be a bit stressed out about this. I agree with your clinical judgement. But, if you are going to freak out from every imperfection in the system, you are going to have a hard time in anesthesia. I deal with sick pt's coming for big arse procedures, yet no labs, no stress test, no ekg, cardiology clearance notes basically saying "pt may benefit from icd, revasc...bla blah blah.., or not.... who the f.... knows....proceed at your own risk", dated the same day of the procedure, everyday. If I want an INR, LFT, stress test, FFP,.... whatever.... I order it myself. I don't have to ask Winnie the pooh for his opinion.

If you can learn something from the anesthesiologist over there is his attitude. Regardless of how coagulopathic that pt might be he is unlikely to bleed to death from said procedure. So, why fuzz about it?

 

[Jeff05]

umm, this guy is not a good candidate for a completely elective surgery.

he's an alcoholic and will go into withdrawal. so, ahh, midazolam infusion in the pacu and he must go to ICU setting for benzo taper. or, have him detoxed first. this will not happen though.

you really should have coags and platelets before going ahead with this COMPLETELY ELECTIVE surgery. or, have some FFP/platelets on hand.

take what the FMG VA anesthesiologist tells you with a grain of salt.

 

[Planktonmd]

take what the IMG VA anesthesiologist tells you with a grain of salt.

How did you know he was an IMG?

 

[Jeff05]

i retract IMG. I meant FMG.

 

[Planktonmd]

i retract IMG. I meant FMG.

And this would make him automatically stupid?

 

[badgas]

As always, this thread in going in the wrong direction. To clarify, the attending is not an FMG/IMG. American grad from a respected residency program. Has the gig for the sweet schedule and no need for $$.

Thanks for the thoughts. I just wanted to hear what some other non VA attendings thought about the situation. I didn't mean to sound stressed because I was not. I wanted to stress that the case was very elective and how things were working in the twilight zone better known as the VA. What goes on there isn't always what should go on in the real world. I wanted to know what SHOULD be done in that situation. Again, it's the VA, so the "STAT" labs ordered had yet to be drawn after several hours. So if the pt bleeds like mad, has another MI and dies, are you not in trouble if the family wants to sue someone? Is it always full steam ahead on elective procedures despite not having labs in people with significant diseases? For example, if the pt was having chest pain in pre op, do we go ahead without EKG because it's probably indigestion? Or do you CYA a little bit? Like I said, I'm still an intern and would like to learn the right way to make these decisions in the future.

As far as the INR is concerned, I shouldn't have said useless. INR levels are much more useful in a patient on coumadin. They are not a good marker of coagulation derangement in a pt with liver disease due to reagents used. If you are comparing old INRs to new INRs in a patient not on coumadin, you have to make sure that the exact same thromboplastin reagents are used, otherwise values can be off by 3 or more in either direction.

 

[Jeff05]

not automatically stupid. but, the FMGs I have had the opportunity to work with at "outside" locations have been "less than."

to the intern:
dude, the The INR is the ratio of a patient's prothrombin time to a normal (control) sample, raised to the power of the ISI value for the control sample used. the reagents are not that different. yes, theoretically, you can have different values from different batches. but, in this case you're not comparing to patient's old values. you just want to know what the INR is at that time. and the INR is a good indicator of liver dysfunction - IT'S A PART OF THE MELD SCORE.

what SHOULD be done if you actually want the best for your patients is not to take this ALCOHOLIC CIRRHOTIC FOR A COSMETIC SURGERY WHEN HE IS LIKELY COAGULOPATHIC. PERIOD.

 

[Planktonmd]

As far as the INR is concerned, I shouldn't have said useless. INR levels are much more useful in a patient on coumadin. They are not a good marker of coagulation derangement in a pt with liver disease due to reagents used. If you are comparing old INRs to new INRs in a patient not on coumadin, you have to make sure that the exact same thromboplastin reagents are used, otherwise values can be off by 3 or more in either direction.

It's actually the exact opposite of what you said:
The INR is the ratio of the patient's PT to a sample PT raised to the power of ISI which is specific for that batch of the tissue factor and eliminates differences between different labs and different reagents.
PT on the other hand is subject to differences in reagents used and the normal range is different for each lab.
Look it up

 

[urge]

1 I didn't mean to sound stressed because I was not..... So if the pt bleeds like mad, has another MI and dies, are you not in trouble if the family wants to sue someone?

2 For example, if the pt was having chest pain in pre op, do we go ahead without EKG because it's probably indigestion? Or do you CYA a little bit?

3 As far as the INR is concerned...

1 I repeat, your judgment is right but your attitude is not. In your mind you are still killing the pt and getting sued. That attitude will drive you insane in this job. Choose carefully. How will you feel when you have to take care of an ASA 5E pt? Chances are pt will die and chances are family will sue. Why get involved?

2 What do you think?


3 I doubt you understand the concept of INR.

 

[drccw]

I do understand that teh concept of STAT at the VA is a little different than in the real world.. but I've spent considerable time at the VA (even considered taking a job there... and no I am not a FMG) and in the OR our coags come back staty! (30-40 mins). You just have to draw them yourselves and have everything ready to go... what takes a while is on the floor. when you tell the nurse you want coags STAT, then she says put it in the computer, then you put it in the computer, and the nurse says you ordered it lab collect not ward collect or whatever, fix it, etc etc etc etc.. and then the nurse is like I suck at drawing blood..... but I digress

 

[Leverage]

I don’t know jack but it seems like this guy is a mess for an elective cosmetic procedure. Aside from likely component of cirrhosis and etoh dependence (bleeding hx and gynecomastica)…Dude is carrying walking around with CAD, DM, and CKD (probably stage 3-4, don’t know weight). Just seems like were worried about some bleeding and like half the drugs we use depress myocardial function and drop pressures. Just thinking pretty high risk factors for prerenal ARF, not good for mortality risk. My gestalt is this guy should quit drinking and then we can help make him look good.

Again, I don’t know jack (not even and intern yet), but what do you all think about risk benefit ratio for this guy?

Is this pretty common?

 

[badgas]

not automatically stupid. but, the FMGs I have had the opportunity to work with at "outside" locations have been "less than."

to the intern:
dude, the The INR is the ratio of a patient's prothrombin time to a normal (control) sample, raised to the power of the ISI value for the control sample used. the reagents are not that different. yes, theoretically, you can have different values from different batches. but, in this case you're not comparing to patient's old values. you just want to know what the INR is at that time. and the INR is a good indicator of liver dysfunction - IT'S A PART OF THE MELD SCORE.

what SHOULD be done if you actually want the best for your patients is not to take this ALCOHOLIC CIRRHOTIC FOR A COSMETIC SURGERY WHEN HE IS LIKELY COAGULOPATHIC. PERIOD.

I like that you brought up the MELD score. Here is an abstract from a study involving just that. Very small study, but interesting.

"Priority for liver transplantation is based on the Model for Endstage Liver Disease (MELD) score, a mathematical function which includes international normalized ratio (INR). We present an analysis to determine the lab-to-lab variation in INR at 14 clinical laboratories across the United States. We performed a survey to identify representative clinical laboratories across the United States, where INR was measured in the determination of MELD score. Five 'standard' samples for INR were formulated and were sent to the 14 clinical laboratories to determine variation in INR and MELD score. Among the 14 clinical laboratories, the range in INR for the five samples was: sample 1 (1.2-2.0), sample 2 (1.4-2.5), sample 3 (1.7-3.4), sample 4 (1.9-3.7) and sample 5 (2.4-5.1). The range in calculated MELD score was: sample 1 (8-14), sample 2 (10-17), sample 3 (12-20), sample 4 (14-21) and sample 5 (16-25). The selection of the clinical laboratory used to determine INR may result in substantial changes in MELD score independent of severity-of-illness. These data suggest that further review of interlaboratory variation in MELD should be undertaken because of the potential impact on prioritization for liver transplantation."

- Am J Transplant. 2007 Jun;7(6):1624-8.

 

[Laurel123]

This guy is your typical VA guy. It is about getting him the best he can get for what is generally a low risk procedure. Are you going to get him into rehab and AA and counseling to stop drinking, a renal transplant and a CABG before his mastectemy? I dont think so.

And it is important to just take a look at him. Is he functioning well? Or is he sitting there with a big ascitic belly, spiders, yellow eyes and flapping his hands?

 

[Planktonmd]

I like that you brought up the MELD score. Here is an abstract from a study involving just that. Very small study, but interesting.

"Priority for liver transplantation is based on the Model for Endstage Liver Disease (MELD) score, a mathematical function which includes international normalized ratio (INR). We present an analysis to determine the lab-to-lab variation in INR at 14 clinical laboratories across the United States. We performed a survey to identify representative clinical laboratories across the United States, where INR was measured in the determination of MELD score. Five 'standard' samples for INR were formulated and were sent to the 14 clinical laboratories to determine variation in INR and MELD score. Among the 14 clinical laboratories, the range in INR for the five samples was: sample 1 (1.2-2.0), sample 2 (1.4-2.5), sample 3 (1.7-3.4), sample 4 (1.9-3.7) and sample 5 (2.4-5.1). The range in calculated MELD score was: sample 1 (8-14), sample 2 (10-17), sample 3 (12-20), sample 4 (14-21) and sample 5 (16-25). The selection of the clinical laboratory used to determine INR may result in substantial changes in MELD score independent of severity-of-illness. These data suggest that further review of interlaboratory variation in MELD should be undertaken because of the potential impact on prioritization for liver transplantation."

- Am J Transplant. 2007 Jun;7(6):1624-8.

So, how does this study show that PT is a more reliable number than INR?
If these 14 labs reported such a wide range of variation in INR it also means that they got the same variation in PT.
It only shows that these 14 labs actually suck.

 

[badgas]

I know what an INR is and the formula. I didn't go into much detail because it wasn't the point of the post. Did I use the INR correctly in clinical terms when I said it was useless... absolutely not. If the guys INR was >8.0 I wouldn't have said it is irrelevant. I did a rotation in path where the pathologist pounded into my head that an INR is useless if the patient is not on coumadin. He said that all of the studies dealing with INR were designed and tested on patients on coumadin so you can't apply it to everything. Liver disease has a different pattern of changes in vit. K dependent and vit. K independent anticoagulants and procoagulant factors. Here are relevant points from his ppt:

•INR is intended only for initial and serial guidance in patients on oral anticoagulants
•INR has not been generally accepted as a guidance for assessing bleeding tendency or therapeutic reversal of elevated PT’s in patients not receiving oral anticoagulants
•The success and routine reporting of the INR has resulted in physicians applying the INR to the assessment of hemostatic dysfunction in patients with liver disease, whose prolonged PT has not been induced by anticoagulant therapy.
•The ability of the INR to provide standardization for this purpose has received scant attention in the medical literature, nor has any consensus on the likelihood of thrombosis or bleeding for a given INR been reached for liver disease as it has been for anticoagulants.
•Kovacs MJ, Wong A, MacKinnon K, et al. Assessment of the validity of the INR system for patients with liver impairment. Thromb Haemost 1994;71:727-30.
–Samples were collected from patients with liver disease and compared with those from a control group of patients on oral anticoagulants.
–Prothrombin times were measured on all samples using three thromboplastin reagents with differing ISIs.
–INRs from patients with liver disease correlated poorly, unlike those from orally anticoagulated patients.
•Studies repeated in the UCSF Clinical Laboratories
–performed PTs with three different reagents on 20 patients with liver disease and 31 patients receiving oral anticoagulants.
–The INRs of the anticoagulated patients ranged from 1.7-5.2 and were similar whichever reagent was used, varying only by 0.1-0.3.
–The INRs of the patients with liver disease, however, which ranged from 1.4-15.9, varied from 0.4-10.5 depending upon the reagent system employed.

So that is where I was coming from.

I'm here to pick up the tricks of the trade, not argue over INRs or FMGs. Nit-picking over INR crap like that was not my intention and looking back at it, it's probably silly to think like a pathologist! Like plankton said, if the INR is up, obviously the PT will be too.

 

[badgas]

So, how does this study show that PT is a more reliable number than INR?
If these 14 labs reported such a wide range of variation in INR it also means that they got the same variation in PT.
It only shows that these 14 labs actually suck.

Exactly what I have been confused about. Like I said, pathologist preached never to use INR in non coumadin patients, but why would PT be any better in terms of consistency? That is where I'm a bit lost. I believe there is work to create an INR for patients with liver disease but obviously nothing perfected yet.

J Thromb Haemost. 2008 Feb;6(2):243-8. Epub 2007 Nov 6.

 

[badgas]

1 I repeat, your judgment is right but your attitude is not. In your mind you are still killing the pt and getting sued. That attitude will drive you insane in this job. Choose carefully. How will you feel when you have to take care of an ASA 5E pt? Chances are pt will die and chances are family will sue. Why get involved?

2 What do you think?


3 I doubt you understand the concept of INR.

Thanks urge. That is what I am after. I want to know where to draw the line. Finishing up IM internship, we practice COMPLETE CYA medicine. 105 yr old comes in with numbness in left pinky, they get admitted for "TIA" and MRI, carotid doppler, echo, etc etc. Why? CYA medicine. I do not have a feel of what is considered over-cautious vs. too ballsy in anesthesiology yet. However, an ASA 5E going to the OR would probably be for a relatively necessary surgery right? A cosmetic surgery in a guy with so many comorbidities and no work up currently makes me a little more nervous. Maybe it shouldn't?

 

[badgas]

I do understand that teh concept of STAT at the VA is a little different than in the real world.. but I've spent considerable time at the VA (even considered taking a job there... and no I am not a FMG) and in the OR our coags come back staty! (30-40 mins). You just have to draw them yourselves and have everything ready to go... what takes a while is on the floor. when you tell the nurse you want coags STAT, then she says put it in the computer, then you put it in the computer, and the nurse says you ordered it lab collect not ward collect or whatever, fix it, etc etc etc etc.. and then the nurse is like I suck at drawing blood..... but I digress

I have only been at one VA. Apparently there are good VAs and there are bad VAs. I am not at one of the betters ones. I could write a book on the substandard care I have witnessed there this year alone.

 

[badgas]

This guy is your typical VA guy. It is about getting him the best he can get for what is generally a low risk procedure. Are you going to get him into rehab and AA and counseling to stop drinking, a renal transplant and a CABG before his mastectemy? I dont think so.

And it is important to just take a look at him. Is he functioning well? Or is he sitting there with a big ascitic belly, spiders, yellow eyes and flapping his hands?

He was not functioning well. I would have thought that leaving him with a pair of boobs would be better than taking the risk.

 

[Jeff05]

i agree with you that PT is difficult to standardize via conversion to INR in patients with liver disease. however, INR is still used to assess function of extrinsic pathway. i can tell you that when i start a liver transplant on a guy with INR of 7 vs INR of 1.6, the 7 BLEEDS a lot more.
but, enough with the INR.


here is what i would do in the situation. i would be frank with the patient and let him know that the risks of this procedure are higher for him because of his CAD (what is his EF?), CRI, liver dz, etoh abuse (if you get plt and INR tell him his risk of intraop and postop bleeding is higher). the chance of him getting FFP and PRBC during surgery are high - exposure to Hep C, HIV, transfusion reaction, possible CHF 2/2 volume overload, etc... all for getting his boobs reduced, which will likely grow back anyway. i would suggest that his risks may be decreased by going to a rehab program, etc and document his understanding of this and his refusal to do this. I would document the discussion fully on the chart and as an attachment to anesthesia file. I would document that these issues have been discussed with the surgeon, as well, he is aware and agrees to proceed. the whole thing is completely ******ed. total waste of money.

after that it's pretty simple. if he bleeds give him FFP and PRBC if needed. maybe a pool of platelets if not responding to FFP. make sure he gets some folic acid IV during the procedure and some glucose in the maint. fluid, as well. i would have him on benzo infusion during procedure and in PACU/floor.

 

[Leverage]

the whole thing is completely ******ed. total waste of money.[/quote]

Tax dollars at work.

 

[indo]

Sort of a side question: What was this guy's BMI or how much did he weight?

 

[militarymd]

wah wah wah....what's with the 3rd degree and mental masturbation.....PUT the dude to sleep and be done with it...

Only a FMG/IMG would do otherwise.

 

[Planktonmd]

Only a FMG/IMG would do otherwise.

If I remember correctly you are of asian descent and actually you have an asian name which makes me think that your parents are immigrants.
So, since your parents were not born in this country do you think they have a lower IQ?

 

[badgas]

wah wah wah....what's with the 3rd degree and mental masturbation.....PUT the dude to sleep and be done with it...

Only a FMG/IMG would do otherwise.

He was making fun of people bringing FMG/IMG issues up out of the blue for no apparent reason.

 

[militarymd]

He was making fun of people bringing FMG/IMG issues up out of the blue for no apparent reason.

Badgas,

If you haven't had the pleasure of working with FMG/IMG's, then count yourself as one of the lucky ones.

I have had to work with many FMG's when I was developing my practice, and this is what I learned.....DO NOT EVER HIRE ONE.

I'm sure there are good ones, but why risk it?

My partner who came from a major academic institution in Miami (many FMG's) feels exactly the same way.

 

[Planktonmd]

Badgas,

If you haven't had the pleasure of working with FMG/IMG's, then count yourself as one of the lucky ones.

I have had to work with many FMG's when I was developing my practice, and this is what I learned.....DO NOT EVER HIRE ONE.

I'm sure there are good ones, but why risk it?

My partner who came from a major academic institution in Miami (many FMG's) feels exactly the same way.

Yes,
You should listen to racist Asians and not hire any foreigners.

 

[phillyfornia]

Badgas,

If you haven't had the pleasure of working with FMG/IMG's, then count yourself as one of the lucky ones.

I have had to work with many FMG's when I was developing my practice, and this is what I learned.....DO NOT EVER HIRE ONE.

I'm sure there are good ones, but why risk it?

My partner who came from a major academic institution in Miami (many FMG's) feels exactly the same way.

what about DOs?

 

[HomerSD]

I'm surprised no one has mentioned potential uremic platelet dysfunction in this patient with a cre of 3.4. Besides the coags, a bleeding time might be helpful, or at least DDAVP and platelets on hand should the patient start bleeding out.