How would you manage this case

[dhb]

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Pre-op case from last week:

Dude checks in for TUVR he was on VitK antagonist for a pulmonary embolus in early 2011 bridged with lovenox 100mg/d.

His labs look like this:
Hb 8.3
BUN >300 creat >5
INR 1.44 PTT 70sec
Nl electrolytes

US shows both kidneys at 12cm

 

[W222]

Pre-op case from last week:

Dude checks in for TUVR he was on VitK antagonist for a pulmonary embolus in early 2011 bridged with lovenox 100mg/d.

His labs look like this:
Hb 8.3
BUN >300 creat >5
INR 1.44 PTT 70sec
Nl electrolytes

US shows both kidneys at 12cm

TUVR? Not familiar with this?

What is his baseline renal function? If this is all new then he needs a workup. If this is an open procedure then he may need pre and post-op dialysis? He is on lovenox and his renal function is terrible, he will bleed like stink as this is renally cleared.

 

[jdh71]

TUVR? Not familiar with this?

What is his baseline renal function? If this is all new then he needs a workup. If this is an open procedure then he may need pre and post-op dialysis? He is on lovenox and his renal function is terrible, he will bleed like stink as this is renally cleared.

I don't know why he'd still be on lovenox. I'd be more worried about the BUN and platelet dysfunction. Not to mention he doesn't have a ton of room on his Hgb to begin with. No way I'd even "clear" this guy to make it to your OR in the first place, unless whatever needed to happen was emergent.

 

[Idiopathic]

so he has prostatic obstruction and postrenal azotemia, needs the obstruction removed. whatever the fix is, hes going to need an anesthetic (nephrostomy vs. urostomy vs TURP). Not sure you can justify admitting him and bridging off lovenox with heparin but that would be my choice if he has to remain on long-term anticoagulation. i would also check platelet function.

otherwise if no frank signs of uremia (cardiopulmonary upheaval, mental status abnormality) exist then GETA with LMA, make sure they leave a foley in and monitor the urine and labs postop.

 

[sevoflurane]

TUVR? Not familiar with this?

Tranurethral Vapor Resectin of Prostate. Used in some places for large porstates.

 

[proman]

Assuming this was the first PE, 6 months of anticoagulation would be adequate therapy. LMWH with renal insufficiency is bad news. Either way this case needs to be done to salvage whatever is left of his kidneys. Assuming no contraindications I'd probably do GA with an LMA, second IV.

 

[W222]

Tranurethral Vapor Resectin of Prostate. Used in some places for large porstates.

Ohh, a greenlight. Ahh yes, the scenario makes much more sense now. I would say stop the lovenox and check a factor Xa, see if the urologists want to do a perc nephro tubes and improve his renal function preop (hey, they can then bill for two procedures), DDAVP for PLT dysfunction preop. Then considering everything normalizes then standard GA tube vs LMA.

 

[Idiopathic]

Ohh, a greenlight. Ahh yes, the scenario makes much more sense now. I would say stop the lovenox and check a factor Xa, see if the urologists want to do a perc nephro tubes and improve his renal function preop (hey, they can then bill for two procedures), DDAVP for PLT dysfunction preop. Then considering everything normalizes then standard GA tube vs LMA.

so you would wait a day for it to normalize? How are perc nephrostomy tubes better here than a TUVR? Id rather not have an intraabdominal/retroperitoneal procedure while coagulopathic, at least you could visualize the urethra during the procedure, and you have a way for the bleeding to leave the body.

 

[jwk]

otherwise if no frank signs of uremia (cardiopulmonary upheaval, mental status abnormality) exist then GETA with LMA, make sure they leave a foley in and monitor the urine and labs postop.

GETA with LMA ???

 

[lane]

GETA with LMA ???

fastrach? 😀

 

[W222]

so you would wait a day for it to normalize? How are perc nephrostomy tubes better here than a TUVR? Id rather not have an intraabdominal/retroperitoneal procedure while coagulopathic, at least you could visualize the urethra during the procedure, and you have a way for the bleeding to leave the body.

Perc tubes by IR or urologist done under local. The perc tubes are temporary while the greenlight is a longterm solution. If you choose to go ahead you risk bleeding from the prostate, if you choose to delay you risk knocking off his kidneys; a good middle road is a perc tube or I guess a suprapubic tube would work. Hell, you could always get a nursing student to ram a foley right through that big old prostate and decompress that way.

 

[Idiopathic]

got me - GENERAL with LMA

 

[dhb]

TUVR? Not familiar with this?

Sorry trans urethral bladder resection.

So this dude show up with terminal renal insufficiency with a Hb of 8 which leads to think it's been developing for some time although the fact that the kidneys are enlarged (12cm) indicate he might regain some function after the obstruction is relived.

His coags are not to great; the Pt by itself is ok but added to the PTT which shows accumulation of the lmwh from the CKD and his platelets are uremic.
Would most of you proceed with GA or would you hold for 24h?

 

[proman]

Sorry trans urethral bladder resection.

So this dude show up with terminal renal insufficiency with a Hb of 8 which leads to think it's been developing for some time although the fact that the kidneys are enlarged (12cm) indicate he might regain some function after the obstruction is relived.

His coags are not to great; the Pt by itself is ok but added to the PTT which shows accumulation of the lmwh from the CKD and his platelets are uremic.
Would most of you proceed with GA or would you hold for 24h?

If his bladder obstruction is so bad to result in renal failure then he should have a Foley. That would be a temporary solution under his coags improve.

 

[Idiopathic]

If his bladder obstruction is so bad to result in renal failure then he should have a Foley. That would be a temporary solution under his coags improve.

im working under the assumption that they cannot place a foley. if he can get a foley then he goes home with it and comes back when everything has normalized.