Newly diagnosed DVT and elective surgery

[TrustMe]

Had a case this morning. Pt scheduled for 5-6 hr abdominal case. Supposed to come in from home but came in yesterday through the ER for new pain and swelling in leg. Found to have fully occlusive DVT almost all the way down his leg (proximal femoral down past popliteal). Got single therapeutic dose of lovenox yesterday afternoon. Surgeon still wants to do the case. After consulting multiple colleagues (I'm the new guy here and didn't want to rock the boat without support) I told the surgeon that I would not do the case. What would you all have done? Was I justified? Pt is otherwise fairly deconditioned and in poor shape medically.

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[IlDestriero]

Had a case this morning. Pt scheduled for 5-6 hr abdominal case. Supposed to come in from home but came in yesterday through the ER for new pain and swelling in leg. Found to have fully occlusive DVT almost all the way down his leg (proximal femoral down past popliteal). Got single therapeutic dose of lovenox yesterday afternoon. Surgeon still wants to do the case. After consulting multiple colleagues (I'm the new guy here and didn't want to rock the boat without support) I told the surgeon that I would not do the case. What would you all have done? Was I justified? Pt is otherwise fairly deconditioned and in poor shape medically.

No way, unless it was urgent (cancer).
Maybe a greenfield first.

 

[MTGas2B]

Probably not. What's the case? Most surgeons probably wouldn't want operate on a guy who just bought a couple months of anti coagulation. Maybe clipping toenails with the podiatrist would be okay.

 

[sevoflurane]

A picture says 1000 words:

 

[gasp]

Had a case this morning. Pt scheduled for 5-6 hr abdominal case. Supposed to come in from home but came in yesterday through the ER for new pain and swelling in leg. Found to have fully occlusive DVT almost all the way down his leg (proximal femoral down past popliteal). Got single therapeutic dose of lovenox yesterday afternoon. Surgeon still wants to do the case. After consulting multiple colleagues (I'm the new guy here and didn't want to rock the boat without support) I told the surgeon that I would not do the case. What would you all have done? Was I justified? Pt is otherwise fairly deconditioned and in poor shape medically.

Umm, definitely not for an elective case. Aside from the fact that he just received Lovenox, he will be on anticoagulation for 3-4 months so I don't get why the surgeon is not worried about intra/post - op bleeding. No other medical history is mentioned here but I'm assuming he has some from the description of the fully occlusive dvt all the way down the leg. I think you made the right decision. He needs to me medically optimized and a greenfield wouldn't hurt.

 

[pgg]

Curious, what's the 5-6 hour elective abdominal case?

 

[cchoukal]

People have mentioned the risk of therapeutic anticoagulation, but let's say the surgeon says he isn't worried about that and wants to proceed.

what (if anything) is dangerous about operating on a patient with an acute DVT?

What is the likelihood that it embolizes (see above)?

Does the patient need an evaluation for a hypercoaguable state (was this a provoked DVT? His first?)?

What does it mean to medically optimize a patient with an acute DVT?

(I just assume the surgeon will ask these questions as a part of his trying to convince you not to cancel the case).

 

[gasp]

People have mentioned the risk of therapeutic anticoagulation, but let's say the surgeon says he isn't worried about that and wants to proceed.

what (if anything) is dangerous about operating on a patient with an acute DVT?

What is the likelihood that it embolizes (see above)?

Does the patient need an evaluation for a hypercoaguable state (was this a provoked DVT? His first?)?

What does it mean to medically optimize a patient with an acute DVT?

(I just assume the surgeon will ask these questions as a part of his trying to convince you not to cancel the case).

I would say Medical optimization is not necessarily for the DVT but includes trying to find the cause, location, treating it, filter..etc

I think what I would do in case the surgeon is really pushing for this case even though he understands the risks is to explain to the patient what the risks are and let them decide. Explain to them that they have an increased risk of morbidity and mortality intra/post-op and that you think that he/she should get further workup done to possibly find the cause of the DVT (which may also be in their lung, IVC.. etc) / treat it, and also get a filter to decrease the chances of embolization before doing this elective surgery. Having said that, tell them that you would still be willing to provide their anesthetic if he/she understood everything you said and would like to still proceed without doing any of the things you mentioned. All you need is written consent that you have explained that they have this increased risk of dying/getting sicker and they still want to proceed. If Pt still wants to go ahead, I would still do it. Pt's are smarter these days and usually opt to become optimized. You really cant do much about the surgeons opinion of you if you want to be honest..

 

[TrustMe]

So, we didn't do the case. Surgeon agreed to filter being placed the following day and then surgery the following day. Pt had clear cell CA and renal cell CA and had cystoprostatectomy and partial nephrectomy at the same time a year ago with creation an ileal conduit. He now had a entero-neobladder fistula that has been there for several months, they are not sure where it is at, and it seems to be getting worse. In the meantime he has disease recurrence that is now metastaic and he is on hospice. This procedure is mostly palliative cause the stool in his foley keeps clotting the foley and has to be replaced a lot (was my understanding from talking to the patient and the surgeon). Procedure would have been open abdominal exploration on a belly that has had radiation plus the above mentioned surgery with no clear indication of where the fistula is. So I guess technically it wasn't cancelled, just postponed for 2 days to get an IVC filter. Surgeon still unhappy.

So we know why he has the DVT/is hypercoagulable. He is also thrombocytopenic (likely consumptive from DVT) and surgeon wants to give platelets in the OR.

 

[RxBoy]

So we know why he has the DVT/is hypercoagulable. He is also thrombocytopenic (likely consumptive from DVT) and surgeon wants to give platelets in the OR.

Like discussed above. Talk to pt, let them know increased risk. If they want to proceed with surgery, so be it.

Def would only do it with IV filter in place and no evidence of UE DVT. Surgeon is pissed because the alternative is to therapeutically treat the pt which will take 3 to 6 months.

Def would switch from lovenox to heparin gtt. Not sure if I would prefer to shut off of heparin gtt 2 hr before surgery or let it ride and shut it off if surgeon gets into major blood loss.