Case

[MErc44]

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Residency is winding down for me and my patience is wearing thin.

Last week had an ortho add on, 65 y/o female who according to the surgeons has seen better days. Quote, "she's off pressors and extubated, what more do you want?"

Pt brought directly to OR due to C. dificile. On further review lifelong type 1 diabetic with ESRD on HD MWF. CAD for which she underwent a CABG in the mid 90's 3 vessel. She also had stents of some variety placed in 2005. Also, had a DES placed in her OM-2 on June 6th and I met her in the OR on June 21. On June 20th the ortho intern, without informing anyone, ordered her Plavix and Aspirin to be held morning of surgery👍

She is coming to the OR for removal of infected hardware from her right tibia. Hardware which apparently put her into septic shock.

What would you guys do in a situation like this? What has your experience been with Plavix and DES?

 

[sevoflurane]

What hardware?

Plates and screws/quick case = PUT HER BACK ON PLAVIX and ASA before she clots off her not-even-a month old Stent.

 

[sevoflurane]

Order a "Verify Now" test and determine what her current % inhibition is.

 

[MErc44]

Plates and screws from a previous ORIF.

 

[dhb]

Put her back on plavix fem + pop sciatic block

 

[MD Dreams]

Holding plavix morning of won't do anything to prevent further bleeding. Need at least 7 days. Explain this to ortho and see if they are ok with continuing plavix. Either way insist she continues ASA and give her one Preop. This will provide some degree of protection. If hardware is infected it needs to come out so not really an elective case. Explain to pt all risks and benefits and document like crazy and let ortho know you'll be documenting everything, especially things associated with plavix and ASA. Make sure she's typed and crossed. Make sure she's got good iv access and consider pre induction A line. May be overkill but better to have these things and not need them. Tight control of hemodynamics throughout entire perioperative period including PACU (don't let the pt be tachy while the pacu nurse is charting away). Sounds like a fun case. Ortho will never change, even in private practice. "See bone, must fix". You have to be aggressive with them so that they realize you are the perioperative physician in charge of the pt and not their b$;ch to do their bidding. Residency does get old but stay strong. PP is much better. Make sure pt starts plavix ASAP after surgery no matter what. Enjoy. I love the rush of these cases 🙂

 

[okayplayer]

Put her back on plavix fem + pop sciatic block

From a risk/benefit standpoint this certainly makes the most sense with her recent DES. My question, however, is if ASRA guidelines tell us to treat PNBs the same as neuraxial procedures, what kind of footing would that put you on medicolegally as an individual in the rare event you had an unrecognized hematoma with compression of the sciatic nerve? The femoral is superficial enough that this seems like less of an issue to me.

I think one of the problems with guidelines like these is that it makes it harder to make difficult treatment decisions based on clinical judgement of risk/benefit because you are on unfirm ground medicolegally to go against published practice guidelines.

 

[Idiopathic]

prop sux tube, restart asa and plavix following case. you should have a few days of buffer between stopping antiplatelet meds and sequelae, and i think you have assumed the most risk right now (i wouldnt cancel the case to restart asa/plavix) +/- art line

 

[periopdoc]

Pretty much a slam dunk case. She needs the hardware out ASAP. Stopping Plavix/ ASA on the AM of surgery is a bone-headed move on many levels, but it is inconsequential at this point, just be sure it gets restarted immediately post-op.

The patient gets anesthetic #1 (prop/sux/ETT) cause I am not sticking any needles in her.

- pod

 

[DrBeaker]

I would want to know potassium before sux action. Give asa prior to OR. Restart plavix right after OR. Inform ortho intern how dumb they are.

 

[Gern Blansten]

I agree with you, though not quite as adamant about the no peripheral nerve block stance. With USG regional, I think the risk of hematoma is small. For the femoral, the artery should be easily avoided with USG and easily compressed if entered. The cardiologists stick the femoral on these patients all the time and only rarely have big issues.

 

[MErc44]

Unfortunately the orthodod is of the type who does not prefer regional anesthetics, he won't allow them on any of his patients. I like regional anesthesia and when I finish residency in 72 hours and start in private practice I might try to convince the surgeon of the benefits of a femoral block in this patient. However, the skin overlying the plate in her tibia was the same color as a VAC sponge so I don't know how much sensation she had.

Surgeons were informed that she would be receiving ASA 325 mg and Plavix 75 mg prior to the procedure. No a line, 2 units of prbc's available. induced with 50 mg of propofol 50 mcg of fentanyl, 3.5 LMA spontaneuosly ventilating throughout for a 15 min procedure. She had minimal to no pain in the PACU.

How is Plavix managed where you work? Here the cardiologists seem to each have a different idea re: length of treatment for dual anti platelet therapy after DES.

 

[pgg]

Classic. Ortho stops Plavix on a fresh stent to reduce operative bleeding in a case that's going to be done with a tourniquet.

 

[MD Dreams]

The anesthetic plan is dictated by you. If a regional technique is safer for the patient (not necessarily in this case) then the patients safety overrides the orthopods preference regarding regional. If its truly for elective reasons then the orthopods preference can be taken into account. I guess this is what I mean when I say we have to show that we are the perioperative physician and it upsets me when other physicians, especially, orthopods think we are just there to put the pt to sleep ASAP so that they can take their sweat time on the bone. I understand it's different as a resident. Youll have more clout as an attending.

As far as stents I believe the guidelines are:

1. Bare metal: 6 weeks plavix along with Asa followed by Asa for lifetime

2. DES: plavix plus Asa for life. Not to be interrupted in less than a year unless emergent case. If plavix is interrupted at any time, Asa should be continued because stopping both together is bad news (high risk of thrombosis). Exception would be intracranial case where risk of bleeding in a confined space is very high.

Correct me if I'm wrong.

 

[pgg]

My question, however, is if ASRA guidelines tell us to treat PNBs the same as neuraxial procedures, what kind of footing would that put you on medicolegally as an individual in the rare event you had an unrecognized hematoma with compression of the sciatic nerve?

ASRA guidelines aren't standards. Inherent in the word "guideline" is the understanding that it's acceptable to deviate from them under certain circumstances.

If ever there is a case to consider and reject their Plavix PNB=neuraxial guideline, the mostly-dead old cardiopulmonopath undergoing emergency surgery is it. Document your reasoning and proceed.

Anybody can get sued for anything, but I'd be willing to block this patient whereas I wouldn't block the elective shoulder case in a healthy-except-for-Plavix outpatient.

 

[jwk]

Classic. Ortho stops Plavix on a fresh stent to reduce operative bleeding in a case that's going to be done with a tourniquet.

The bell curve on orthopods must really be skewed towards the lower percentiles - I mean seriously. We rarely see such boneheaded moves with any other surgical specialty (although lately some of our GI endocsopists are making some of the orthopods look rather bright).

Ortho - Hip fx - older than dirt, ASA 4+ - arrests on induction - resuscitated and case cancelled. Two days later, A-line and Swan removed by the intensivist who announces the patient is as good as they're going to get, even though they're still on the vent. Orthopod determined to proceed. Mid-procedure, pt arrests while in lateral decubitis position. The orthopod is informed and says, "OK - hold on - I'll have this rod hammered in in about a minute". DUH! This time patient dies.

VS

GI - Add-on case for "GI Bleed". Pt seen in pre-op, doesn't respond to questions. We asked the patients wife if he's been like this for a while, and she says "Oh no, he just stopped talking two days ago - usually he talks up a storm". GI doc said "hmmmmmmm" when we suggested perhaps the patient had suffered some sort of cerebral event. "Well, can we still scope him?" Uh, no, because if the patient doesn't wake up at the end, who do you think will be blamed? Cancelled.

Gotta love it! 😀

 

[pgg]

The bell curve on orthopods must really be skewed towards the lower percentiles - I mean seriously. We rarely see such boneheaded moves with any other surgical specialty (although lately some of our GI endocsopists are making some of the orthopods look rather bright).

Ortho - Hip fx - older than dirt, ASA 4+ - arrests on induction - resuscitated and case cancelled. Two days later, A-line and Swan removed by the intensivist who announces the patient is as good as they're going to get, even though they're still on the vent. Orthopod determined to proceed. Mid-procedure, pt arrests while in lateral decubitis position. The orthopod is informed and says, "OK - hold on - I'll have this rod hammered in in about a minute". DUH! This time patient dies.

VS

GI - Add-on case for "GI Bleed". Pt seen in pre-op, doesn't respond to questions. We asked the patients wife if he's been like this for a while, and she says "Oh no, he just stopped talking two days ago - usually he talks up a storm". GI doc said "hmmmmmmm" when we suggested perhaps the patient had suffered some sort of cerebral event. "Well, can we still scope him?" Uh, no, because if the patient doesn't wake up at the end, who do you think will be blamed? Cancelled.

Gotta love it! 😀

Heh, in ortho's defense, it was an intern, and at least he didn't order a PFA100 platelet assay too ... 🙂

 

[Oggg]

Your ortho attending may be worried about compartment syndrome? How about Nerve blocks with lidocaine only?

 

[proman]

Heh, in ortho's defense, it was an intern, and at least he didn't order a PFA100 platelet assay too ... 🙂

Scary though because an ortho intern is at the pinnacle of medical knowledge for the remainder of his career.

 

[BLADEMDA]

Your ortho attending may be worried about compartment syndrome? How about Nerve blocks with lidocaine only?

Or an LMA if the saturation and resp rate look decent preop. This is a 30 min case in my practice.

 

[MErc44]

Orthopod does lots of trauma work so it is my undstanding that the risk of compartment syndrome is what drives him away from regional anesthesia. LMA worked nicely.

 

[fakin' the funk]

Classic. Ortho stops Plavix on a fresh stent to reduce operative bleeding in a case that's going to be done with a tourniquet.

+1.

Give ASA preop and plavix post-op. Call cardiology.

 

[Bertelman]

Or an LMA if the saturation and resp rate look decent preop. This is a 30 min case in my practice.

Of course, in your practice ortho would not have d/c'd the Plavix.

 

[Idiopathic]

+1.

Give ASA preop and plavix post-op. Call cardiology.

guys why are we so freaked out by a patient missing one dose of ASA/plavix (not even, since we assume both doses can be given that day, even if given postop). i mean you want to call cards? what are they going to do?

from the plavix insert

"If you miss a dose, take Plavix as soon as you remember. If it is almost time for your next dose, skip the missed dose. Take the next dose at your regular time. Do not take 2 doses of Plavix at the same time unless your doctor tells you to."

 

[jwk]

guys why are we so freaked out by a patient missing one dose of ASA/plavix (not even, since we assume both doses can be given that day, even if given postop).

Well, if they're stupid enough to stop it, they're probably stupid enough to forget to restart it.

 

[pgg]

guys why are we so freaked out by a patient missing one dose of ASA/plavix (not even, since we assume both doses can be given that day, even if given postop). i mean you want to call cards? what are they going to do?

from the plavix insert

"If you miss a dose, take Plavix as soon as you remember. If it is almost time for your next dose, skip the missed dose. Take the next dose at your regular time. Do not take 2 doses of Plavix at the same time unless your doctor tells you to."

It's doing something silly for the wrong reasons, without appreciation for the risks, for a non-benefit.

My medical code of ethics mandates mocking such things, that's all. 🙂

 

[CambieMD]

No one is concerned about gastroparesis in a long standing diabetic.


Cambie

 

[periopdoc]

Well, if they're stupid enough to stop it, they're probably stupid enough to forget to restart it.

Which is neither here nor there in terms of the decision to do the case now. Do it. Tell them to restart it and suggest they get cardiology involved so there is an advocate for appropriate antiplatelet therapy after she leaves your care.

- pod

 

[imfrankie]

Which is neither here nor there in terms of the decision to do the case now. Do it. Tell them to restart it and suggest they get cardiology involved so there is an advocate for appropriate antiplatelet therapy after she leaves your care.

- pod

Give the resident orthopedist a reason to think before acting next time: "Sure hope you didn't give Dr. Ortho Faculty's patient an MI by stopping the dual antiplates. You might want to speak to a cardiologist about that" End of discussion.

 

[Mman]

I would want to know potassium before sux action. Give asa prior to OR. Restart plavix right after OR. Inform ortho intern how dumb they are.

I would also like to know, but what's your cutoff? Any magic number? How high before you postpone the case in a tenuous patient?

From me, this patient is getting an ETT and an arterial line. I'm not doing a sciatic block in a patient on plavix. That's pretty deep and not exactly compressable. Also, there is no evidence in the literature of a mortality benefit to a regional technique compared to GA.

 

[Idiopathic]

No one is concerned about gastroparesis in a long standing diabetic.


Cambie

not if she is asymptomatic

 

[fakin' the funk]

She is coming to the OR for removal of infected hardware from her right tibia. Hardware which apparently put her into septic shock.

Isn't Step 1 of therapy for septic shock "source control?" Seems to me like she shoulda come for removal of hardware earlier.

 

[Idiopathic]

Isn't Step 1 of therapy for septic shock "source control?" Seems to me like she shoulda come for removal of hardware earlier.

im not sure there is a step 1 therapy for septic shock. it certainly is right up there with antibiotics, volume replacement and lactate clearance. perhaps this is a case of "we arent sure what put her into septic shock but this looks infected"

 

[Oggg]

For a tibia, a popliteal sciatic block is fine and it's a shallow block. Even less risk with ultrasound.

Gotta balance the risk of aspiration with LMA with the risk of causing an MI with ETT. Both pretty low risk.

 

[Mman]

For a tibia, a popliteal sciatic block is fine and it's a shallow block. Even less risk with ultrasound.

Gotta balance the risk of aspiration with LMA with the risk of causing an MI with ETT. Both pretty low risk.

Pretty sure I've never seen the cardiologist note that the patient had an MI from their ETT. Tough to block a coronary from the trachea. If it did, we'd probably have to stop using ETTs on all those CABGs.

 

[Idiopathic]

For a tibia, a popliteal sciatic block is fine and it's a shallow block. Even less risk with ultrasound.

Gotta balance the risk of aspiration with LMA with the risk of causing an MI with ETT. Both pretty low risk.

risk of a perioperative MI is probably not reduced with regional, and shouldnt be higher with an ETT than with an LMA.

 

[Mman]

risk of a perioperative MI is probably not reduced with regional, and shouldnt be higher with an ETT than with an LMA.

You are correct. A regional technique doesn't change the risk of cardiac morbidity/mortality, nor does an LMA compared to an ETT.