Good Times With Ortho

[pgg]

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aka it's Friday night and there is a fracture I need to fix it


84 year old female added on for a shoulder hemi-arthroplasty after an ugly proximal humerus fracture.

PMHx -
- coronary disease stented a few years ago
- cerebrovascular disease s/p a series of TIAs and small strokes over the years with some resulting mild dementia
- poorly controlled hypertension
- chronic anemia, there are some notes about its perniciousness and she's been getting B12
- eats, but has a PEG
- otherwise the picture of geriatric health

Took her Plavix up until yesterday.

ECG is sinus
Hb 7.9 today, other labs are OK
BP seems to live in the 150-170/80-100 range.

Ortho says he needs to do the case in the sitting position and wants to go to the OR as soon as the PFA-100 he ordered comes back, assuming it's "not too abnormal".


What to do ...

 

[urge]

aka it's Friday night and there is a fracture I need to fix it


go to the OR as soon as the PFA-100 he ordered comes back, assuming it's "not too abnormal".

Is that thing reliable?

 

[pgg]

Is that thing reliable?

Presumably it does what it was designed and FDA-OK'd to do ... 😉

 

[Mman]

aka it's Friday night and there is a fracture I need to fix it


84 year old female added on for a shoulder hemi-arthroplasty after an ugly proximal humerus fracture.

PMHx -
- coronary disease stented a few years ago
- cerebrovascular disease s/p a series of TIAs and small strokes over the years with some resulting mild dementia
- poorly controlled hypertension
- chronic anemia, there are some notes about its perniciousness and she's been getting B12
- eats, but has a PEG
- otherwise the picture of geriatric health

Took her Plavix up until yesterday.

ECG is sinus
Hb 7.9 today, other labs are OK
BP seems to live in the 150-170/80-100 range.

Ortho says he needs to do the case in the sitting position and wants to go to the OR as soon as the PFA-100 he ordered comes back, assuming it's "not too abnormal".


What to do ...

I guess I'd inform him and the patient that she is at significant risk of adverse outcome solely from the sitting position and it's impact on her cerebral perfusion. I mean she's got at least 3 strikes against her: she's 84, she's got known cerebral vascular disease, and she's a poorly controlled hypertensive.

If the case still needs to happen in that fashion, just try to maximize her cerebral oxygen delivery throughout the case. Could put a cerebral oximeter on, but I'm guessing the numbers would be ugly even from the start and I doubt it would change management. Probably some argument to be made in terms of performing the case under regional compared to GA, odds of signficant bleed from U/S guided supraclavicular block are pretty low even while anticoagulated.

Interesting case.

 

[Idiopathic]

a little pain may be good for her, id just fly with prop/sux/tube, +/- art line two IVs and absolutely put cerebral oximetry on; at best you can say it was normal throughout the case, at worst, you can have something to optimize.

 

[cincincyreds]

Was there ever an echo done? I had a similar case as you described with a patient with severe pulmonary HTN/ mitral stenosis and the surgeon said it had to be done beachchair. Patient died a few hours later in the SICU after I dropped her off for the operation. I was going to do a block but she just wouldn't cooperate and stay still, so I just Prop/Sux/tubed her with an a-line, CVP, and 2 large bore IVs and sent her to the unit with a tube.

I'm assuming the stress from the case put her into right heart failure and that ended the ballgame.

 

[proman]

Check a P2Y12. Takes less than 20 min. The benefits of an ultrasound guided posterior approach IS catheter far outweigh the risks. Minimal sedation.

 

[Jeff Smoker]

A view from the other side of the fence...

As an ortho resident, I guess I don't really understand the "urgency" of this case. I've done my fair share of hemis for blasted, osteoporotic proximal humerus fractures. It certainly doesn't need to be done on a Friday night (or that day, or that weekend, or even that week) and not before she's "medically optimized." Now, that phrase may mean different things to different people, and she may be as "optimized" as she's gonna get, but I don't think there's any need to run to the OR for this. Did your orthopod give you any insight into why he needed to do it right then and there?

 

[pgg]

Was there ever an echo done?

There was an echo from ~6 months prior, EF 50%, mild LVH, good valves. Exercise tolerance is nil, she just hangs out and watches TV, but she doesn't have symptoms.


Hemi shoulders with this orthopod are usually 2-3 hours and bloody. He has a habit of asking what the blood pressure is, and (whatever it is) if I can get it down a bit.


I thought this case was a disaster waiting to happen.

Anemic to start - though ortho had ordered a unit of blood preop.

On Plavix ... surgeon got a platelet function test. I even went to the trouble of having the lab talk to him about the limitations of the PFA-100 and its insensitivity to Plavix, but the orthopod said "in my experience it seems to be an OK measure" ...

Needed to be done sitting. I told him that when we did the case, I wouldn't be able to safely get her BP down much, because of cerebral perfusion and she'd bleed more.

With him I expect 500-1000 of blood loss for a hemi shoulder on a good day, with no Plavix and a normal BP.

We did talk about a block briefly, but between her dementia and the Plavix I didn't want to go there.

No cerebral oximeter available.

 

[pgg]

Check a P2Y12. Takes less than 20 min. The benefits of an ultrasound guided posterior approach IS catheter far outweigh the risks. Minimal sedation.

PFA-100 is the only platelet function assay the lab had available.

I was reluctant to go regional because of the Plavix and suspicion that she couldn't hold still.

 

[pmichaelmd]

That is a tough call. He has already demonstrated that he has little interest in understanding how Plavix works and how the beach chair position will affect cerebral oxygenation. Do you have a pretty good relationship with your orthopedic surgeons? Our ortho guys are, by and large, pretty cool and seem to listen to our advice. I usually bring such issues as "medical emergency vs medical urgency" to their attention early and present things in such a fashion as to highlight the fact that I would like to keep the patient alive and both of us out of court. I also carefully use language, ie I never "cancel" a case, simply "postpone until medically appropriate."

All of that said, if we disagree about the level of urgency in doing the case, I optimize the patient as best I can, tell him to document that he deems this to be a medical emergency, and that we will proceed, understanding the risks involved. He knows I will be documenting said conversation as well. If he truly believes it is, in all actuality, an emergency, he will proceed. If he knows it is BS, he will usually stop short of signing his name to the word "emergency."

Also, although I tent to find the cerebral oximeter to be kinda flaky as an absolute measure of cerebral oxygenation, I am not against using it to obtain a baseline value.

Thus goes the game, I guess.

What did you do?

 

[pgg]

After 3 years of working with this guy, I'm still not sure if I'd call the relationship a good one. He has a habit for really grossly overbooking his days, and most Fridays with him consist of 5 or 6 total joints plus a handful of add-ons running late into the evening, usually spilling over onto Saturday. He also tends to disappear between cases while he goes round or pops into his office for something. Neither of which makes him any friends with the OR crews ...

He is pretty anti-regional ... a lot of that I think is because he's been bitten by schedule hiccups waiting for blocks by slow people. But he's not opposed to blocks when they're really medically indicated. Again I was reluctant to block this patient partly because of the Plavix but mostly because I didn't expect a cooperative patient. And it wasn't so much pain or general anesthesia that I feared, as blood loss and cerebral perfusion issues.

He will push these "urgent" cases as far as anesthesia will let him ...



I told him we should delay the case, probably until Monday, specifically to get her transfused and to give her a few days off the Plavix. I didn't see the hurry to get it done on a weekend. She was at risk for a lot of blood loss and cerebral ischemia. He said we should just transfuse some platelets. He was also adamant about doing the case in the beach chair position; I don't know enough about ortho to say if that was just him being inflexible or if going lateral really does make it super difficult.

While waiting for the PFA-100 we talked about it and Plavix, even got the lab on the phone to discuss its limitations. He did acknowledge its limitations but stuck to his belief that it's useful. I was concerned that it would come back normal and he'd be falsely reassured that there was nothing wrong. The last time I postponed one of his cases for a whole 12 hours he said OK and 4 minutes later called his favorite group partner to gripe about it.

As it happened, the PFA-100 came back as very abnormal (validating his belief that it effectively measures Plavix effects), so he was agreeable to a delay ... but not all the way to Monday (clinic that day). He wanted to go Saturday but then saw another orthopod already had a couple of fractures on, and he didn't want to follow, so he pushed it to Sunday morning. He did end up modifying his plan, too, which was an absolute first. I've never seen him modify his plan based on pansy anesthesia concerns. Instead of a hemi arthroplasty, he did an ORIF of some flavor (about 300-400 of blood loss). And they transfused some platelets just prior to going to the OR.

The person who ended up doing the case gave her a straight general, no block. Patient did fine.



So the main question I wanted to pose the forum here is whether or not any of you are transfusing platelets to get Plavix patients to the OR faster, or to reduce bleeding in expected bloody procedures. How soon after the last dose is this worthwhile?

Although affected platelets are nonsticky for the rest of their life span, the active metabolite of the Plavix prodrug has a 1/2 life of about 8 hours I think, so I'm thinking that any platelets transfused in the first 24-48 hrs are going to get promptly whacked and be useless.

 

[Idiopathic]

So the main question I wanted to pose the forum here is whether or not any of you are transfusing platelets to get Plavix patients to the OR faster, or to reduce bleeding in expected bloody procedures. How soon after the last dose is this worthwhile?

Although affected platelets are nonsticky for the rest of their life span, the active metabolite of the Plavix prodrug has a 1/2 life of about 8 hours I think, so I'm thinking that any platelets transfused in the first 24-48 hrs are going to get promptly whacked and be useless.

Have done it before; would consider it, based on the procedure, 0-5 days out from the last dose. I think your point is good that <24 hours from the last dose giving platelets ends up being damage control and probably should not happen before you need them, but after 2 days out I think you should consider them preop. you wont ever completely correct platelet function in this situaion, but in certain cases, it could help.

 

[proman]

So the main question I wanted to pose the forum here is whether or not any of you are transfusing platelets to get Plavix patients to the OR faster, or to reduce bleeding in expected bloody procedures. How soon after the last dose is this worthwhile?

Although affected platelets are nonsticky for the rest of their life span, the active metabolite of the Plavix prodrug has a 1/2 life of about 8 hours I think, so I'm thinking that any platelets transfused in the first 24-48 hrs are going to get promptly whacked and be useless.

Understanding the limitations of the hospital, the P2Y12 test is really the best guide out there. I've done a lot of CABs in patients who got Plavix 600mg the day before. Some bleed like hell, some are dry. With the P2Y12 you know % platelet inhibition and you can predict who will need 0 platelets and who will need 3 bags. I don't know that information with the PFA.

I'd just keep the pressure at baseline. If the surgeon complains of bleeding I'd just be ready to transfuse more. Overall glad it worked out.

 

[bullard]

a little pain may be good for her, i

I'm not sure I understand how this works.

 

[bullard]

Understanding the limitations of the hospital, the P2Y12 test is really the best guide out there. I've done a lot of CABs in patients who got Plavix 600mg the day before. Some bleed like hell, some are dry. With the P2Y12 you know % platelet inhibition and you can predict who will need 0 platelets and who will need 3 bags. I don't know that information with the PFA.

Great post. The neurosurgeons during residency would frequently order a P2Y12 assay but I didn't realize it was that valuable.

 

[Oggg]

Pain is good sometimes when it keeps the patient's BP up. Pain is bad when they are so sick they can't tolerate the stress of surgery. I agree with postponing for plavix to wear off a bit for surgical bleeding. I think a good ultrasound block is a great idea, plus a light general w/LMA, and some presssors to keep the BP up. Transfuse her to Hgb 10 ASAP. block under GA if she can't hold still.

 

[Jay K]

Nice thread, pgg. I'm always surprised (though I shouldn't be) how similar everyone's experience can be in private practice and their dealings with surgeons/scenarios.

 

[Mman]

Pain is good sometimes when it keeps the patient's BP up. Pain is bad when they are so sick they can't tolerate the stress of surgery. I agree with postponing for plavix to wear off a bit for surgical bleeding. I think a good ultrasound block is a great idea, plus a light general w/LMA, and some presssors to keep the BP up. Transfuse her to Hgb 10 ASAP. block under GA if she can't hold still.

Is there some kind of benefit an LMA provides over an ETT I'm not aware of? Personally I'd rather not risk the chance of an LMA not seating perfectly and ending up with some half asses ventilation halfway through the case leading to hypercarbia and right heart failure. I'd just tube her, paralyze her, and keep her on enough gas to not remember. No need to get cute with someone who is teetering on the edge of something bad IMHO.

 

[MRW]

Is there some kind of benefit an LMA provides over an ETT I'm not aware of? Personally I'd rather not risk the chance of an LMA not seating perfectly and ending up with some half asses ventilation halfway through the case leading to hypercarbia and right heart failure. I'd just tube her, paralyze her, and keep her on enough gas to not remember. No need to get cute with someone who is teetering on the edge of something bad IMHO.

The LMA doesn't stimulate the trachea and vocal cords. Nothing that can't be dealt with using lido jelly or an LTA, but for this case perhaps it would be of benefit. Personally, I'd rather have a tube when in beach chair, but its certainly not an absolute.

 

[BLADEMDA]

Understanding the limitations of the hospital, the P2Y12 test is really the best guide out there. I've done a lot of CABs in patients who got Plavix 600mg the day before. Some bleed like hell, some are dry. With the P2Y12 you know % platelet inhibition and you can predict who will need 0 platelets and who will need 3 bags. I don't know that information with the PFA.

I'd just keep the pressure at baseline. If the surgeon complains of bleeding I'd just be ready to transfuse more. Overall glad it worked out.

That is correct. I have both tests avail. to me and the P2Y12 is the better lab test for Plavix and Effient.

PFA-100 is more of a general lab test for clotting/platelet function.

Device Intended Use:

The Dade® PFA-100® Platelet Function Analyzer and associated

reagents are

in vitro diagnostic devices intended to aid in the detection of

platelet dysfunction in citrated human whole blood.

 

[sevoflurane]

Although affected platelets are nonsticky for the rest of their life span, the active metabolite of the Plavix prodrug has a 1/2 life of about 8 hours I think, so I'm thinking that any platelets transfused in the first 24-48 hrs are going to get promptly whacked and be useless.

Yeah man. I wouldn't transfuse platelets w/in a couple of days of the last plavix dose. I think you would be exposing her to products unnecessarily and would be inhibiting those platelets as soon as they hit the circulation. You might get a benefit after 72 hrs, but I'm not sure if this has been studied.

If the case needs to go 2/2 neurological deficits and you think he's going to loose up to 1+L of blood with the surgery you may consider DDAVP and/or an antifibrinolytic like amicar. Although the mechanism of action differs from clopidogre and aspirinl, increasing factor VIII and vWF may be useful and adding an antifibrinolytic might keep you from administering excessive products. This has not been studied extensively and some would say DDAVP would have minimal effects if any. However, there are some studies that show a benefit when trying to reduce bleeding secondary to aspirin administration. It's great for uremic, hemophelia A and vWD. DDAVP works quickly and doens't last long, so good profile for an OR case. Watch out though... DDAVP can cause significant hypotension. Give it slow. The patient will likely still bleed, but maybe not as much.

Risk stratification with regards to her stent and cerebral circulation needs to be addressed of course.

 

[sevoflurane]

+1 on the "VarifyNow". It's a great test.

 

[fakin' the funk]

The LMA doesn't stimulate the trachea and vocal cords.

Right...that's why patients with LMAs never laryngospasm. 🙄

 

[MRW]

Right...that's why patients with LMAs never laryngospasm. 🙄

Well fair enough, but that can at least partially be ascribed to secretions, no? Still, it is not the same as a tube through your cords and an inflated baloon in your trachea. Patients don't generally buck on an LMA...

 

[proman]

+1 on the "VarifyNow". It's a great test.

I did an aortobifemoral bypass today. Patient had been on Plavix 75mg daily for 5 years. Checked a Verify Now and it showed <1% inhibition. The field was dry. No microvascular ooze like we've all seen with patients taking Plavix. So basically the patient has been wasting thousands of dollars on Plavix.

 

[DrBeaker]

Well fair enough, but that can at least partially be ascribed to secretions, no? Still, it is not the same as a tube through your cords and an inflated baloon in your trachea. Patients don't generally buck on an LMA...

The pharynx and larynx both have sensory nerves which aid in providing protective airway reflexes above the cords. An LMA is better tolerated but people "buck" with them.

 

[Mman]

The LMA doesn't stimulate the trachea and vocal cords. Nothing that can't be dealt with using lido jelly or an LTA, but for this case perhaps it would be of benefit. Personally, I'd rather have a tube when in beach chair, but its certainly not an absolute.

In a patient I'm worried about maintaining cerebral perfusion in, a little endotracheal stimulation is not necessarily a bad thing. In fact, it's probably a good thing. And guaranteeing perfect ventilation is far more important to me.

 

[pgg]

In a patient I'm worried about maintaining cerebral perfusion in, a little endotracheal stimulation is not necessarily a bad thing. In fact, it's probably a good thing. And guaranteeing perfect ventilation is far more important to me.

Plenty of times I've regretted putting in an LMA. Can't say I've ever said to myself, 'man I wish I hadn't intubated that sitting/lateral/prone/sick patient' ... so a big +1 "me too" on a tube. I've progressively become more and more disinfatuated with LMAs in general, except for easy fast cases in healthy people.

But I prefer vasoactive drugs to keep their perfusion where I want it, over pain. Tracheal stimulation just seems an imprecise, unpredictable, and kludgy way to keep hemodynamic #s in the box; I know lots of people like to use in situ catecholamines as their vasopressor of choice, maybe I was just doing it wrong or never got the hang of it. These days I often put a bag of phenylephrine on a pump and run 25 or 50 mcg/min into a patient for a while. Even healthy patients who don't fit the usual 'needs a vasopressor' profile ... it lets me run a little more volatile agent, maybe a bit less narcotic.

 

[MRW]

In a patient I'm worried about maintaining cerebral perfusion in, a little endotracheal stimulation is not necessarily a bad thing. In fact, it's probably a good thing. And guaranteeing perfect ventilation is far more important to me.

I think you'll see that was my assertion too.

 

[gclax30]

Haven't given a lot of platelets yet in my young career (CA 1), but I would be concerned with transfusing platelets in a patient with known coronary disease, especially for a seemingly non-emergent case. At what point does the benefit of giving platelets (less bleeding, getting to the O.R. faster) outweigh the risk in this particular patient?

 

[cchoukal]

Haven't given a lot of platelets yet in my young career (CA 1), but I would be concerned with transfusing platelets in a patient with known coronary disease, especially for a seemingly non-emergent case. At what point does the benefit of giving platelets (less bleeding, getting to the O.R. faster) outweigh the risk in this particular patient?

I think the meta-question you're asking is "do transfused platelets increase the likelihood of in-stent thrombosis?"

I'm not sure anyone's answered that question, but I suspect the risks of that outcome are low, particularly, as someone pointed out above, because she still has clopidogrel molecules circulating in her blood that will bind and inactive these fresh platelets (maybe, probably?) and because her stents are old and, probably, epithelialized.

The larger concern, as pointed out above also, is that platelets are a high-risk transfusate. Orders of magnitude higher risk of transmitted bacterial infections compared to RBCs and FFP, and in some populations, higher mortality from an increased incidence of respiratory complications (TRALI) compared to those who don't get platelets.

 

[RT2MD]

Yeah man. I wouldn't transfuse platelets w/in a couple of days of the last plavix dose. I think you would be exposing her to products unnecessarily and would be inhibiting those platelets as soon as they hit the circulation. You might get a benefit after 72 hrs, but I'm not sure if this has been studied.

If the case needs to go 2/2 neurological deficits and you think he's going to loose up to 1+L of blood with the surgery you may consider DDAVP and/or an antifibrinolytic like amicar. Although the mechanism of action differs from clopidogre and aspirinl, increasing factor VIII and vWF may be useful and adding an antifibrinolytic might keep you from administering excessive products. This has not been studied extensively and some would say DDAVP would have minimal effects if any. However, there are some studies that show a benefit when trying to reduce bleeding secondary to aspirin administration. It's great for uremic, hemophelia A and vWD. DDAVP works quickly and doens't last long, so good profile for an OR case. Watch out though... DDAVP can cause significant hypotension. Give it slow. The patient will likely still bleed, but maybe not as much.

Risk stratification with regards to her stent and cerebral circulation needs to be addressed of course.

Great case discussion for a 2nd year student to read though... it's nice to work on putting some of this stuff together... although I had to get pissed at myself b/c the first thing I thought of when reading DDAVP and vWF is Weibel-Palade bodies... really? THAT'S the first thing that comes to my mind about vWF??? I hate Step 1.

 

[Ignatius J]

Discuss the risks and benefits of doing the case with the surgeon. Explain the risks to the patient as well.

Do an interscalene block and maintain on propofol infusion titrated to effect for breathing while maintaining a phenyephrine drip to maintain cerebral perfusion.

Haven't studies shown that the stents are re-endothelialized after about 3 months for BMS and 12 months for DES? Why the need for him to be on Plavix still? I thought the ACA didn't think long-term dual anti-platelet therapy was as necessary anymore.

 

[Ignatius J]

After 3 years of working with this guy, I'm still not sure if I'd call the relationship a good one. He has a habit for really grossly overbooking his days, and most Fridays with him consist of 5 or 6 total joints plus a handful of add-ons running late into the evening, usually spilling over onto Saturday. He also tends to disappear between cases while he goes round or pops into his office for something. Neither of which makes him any friends with the OR crews ...

He is pretty anti-regional ... a lot of that I think is because he's been bitten by schedule hiccups waiting for blocks by slow people. But he's not opposed to blocks when they're really medically indicated. Again I was reluctant to block this patient partly because of the Plavix but mostly because I didn't expect a cooperative patient. And it wasn't so much pain or general anesthesia that I feared, as blood loss and cerebral perfusion issues.

He will push these "urgent" cases as far as anesthesia will let him ...



I told him we should delay the case, probably until Monday, specifically to get her transfused and to give her a few days off the Plavix. I didn't see the hurry to get it done on a weekend. She was at risk for a lot of blood loss and cerebral ischemia. He said we should just transfuse some platelets. He was also adamant about doing the case in the beach chair position; I don't know enough about ortho to say if that was just him being inflexible or if going lateral really does make it super difficult.

While waiting for the PFA-100 we talked about it and Plavix, even got the lab on the phone to discuss its limitations. He did acknowledge its limitations but stuck to his belief that it's useful. I was concerned that it would come back normal and he'd be falsely reassured that there was nothing wrong. The last time I postponed one of his cases for a whole 12 hours he said OK and 4 minutes later called his favorite group partner to gripe about it.

As it happened, the PFA-100 came back as very abnormal (validating his belief that it effectively measures Plavix effects), so he was agreeable to a delay ... but not all the way to Monday (clinic that day). He wanted to go Saturday but then saw another orthopod already had a couple of fractures on, and he didn't want to follow, so he pushed it to Sunday morning. He did end up modifying his plan, too, which was an absolute first. I've never seen him modify his plan based on pansy anesthesia concerns. Instead of a hemi arthroplasty, he did an ORIF of some flavor (about 300-400 of blood loss). And they transfused some platelets just prior to going to the OR.

The person who ended up doing the case gave her a straight general, no block. Patient did fine.



So the main question I wanted to pose the forum here is whether or not any of you are transfusing platelets to get Plavix patients to the OR faster, or to reduce bleeding in expected bloody procedures. How soon after the last dose is this worthwhile?

Although affected platelets are nonsticky for the rest of their life span, the active metabolite of the Plavix prodrug has a 1/2 life of about 8 hours I think, so I'm thinking that any platelets transfused in the first 24-48 hrs are going to get promptly whacked and be useless.

I could be wrong but I thought Plavix exerted it's effect mainly at the megakaryocyte level, so it has little effect on transfused platelets....

 

[Dwindlin]

I could be wrong but I thought Plavix exerted it's effect mainly at the megakaryocyte level, so it has little effect on transfused platelets....

Believe it is actually an ADP antagonist, blocks activation of GPIIb/IIIa, preventing platelets from binding fibrinogen and aggregating.

 

[RT2MD]

Believe it is actually an ADP antagonist, blocks activation of GPIIb/IIIa, preventing platelets from binding fibrinogen and aggregating.

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