Plastic Surgery Case Cancellation

[nofliesonme]

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Plastic surgeon here, I have tremendous respect for good anesthesiologists and learn from this board. I'd like to present a recent case....Patient is a 25 year old female to male transgender patient, 5'0, 160lbs, scheduled for bilateral mastectomy, bilateral nipple areola reconstruction and chest wall liposuction for July 1. Each breast resection will be over 800 grams, total liposuction aspirate estimated to be 500ml and the estimated operative time is 3 1/2 hours. Surgery is in an accredited office operatory. Patient is going home after surgery and lives 2 1/2 hours away. Patient gets 100mg testosterone weekly and has a pre-op Hgb. of 17.1 on 6/24. Morning of surgery patient says 3 days ago my hematologist did a phlebotomy. I call the hematologist, to find out how much blood has been removed but he is on vacation, NP says, "we periodically phlebotomize him,not sure how much blood was removed but at least a unit". I am unable to get a stat CBC. My anesthesiologist is willing to do the case. I cancel the case, and reschedule for later in the week to get an accurate starting H/H. Am I being overly cautious?

 

[chocomorsel]

Plastic surgeon here, I have tremendous respect for good anesthesiologists and learn from this board. I'd like to present a recent case....Patient is a 25 year old female to male transgender patient, 5'0, 160lbs, scheduled for bilateral mastectomy, bilateral nipple areola reconstruction and chest wall liposuction for July 1. Each breast resection will be over 800 grams, total liposuction aspirate estimated to be 500ml and the estimated operative time is 3 1/2 hours. Surgery is in an accredited office operatory. Patient is going home after surgery and lives 2 1/2 hours away. Patient gets 100mg testosterone weekly and has a pre-op Hgb. of 17.1 on 6/24. Morning of surgery patient says 3 days ago my hematologist did a phlebotomy. I call the hematologist, to find out how much blood has been removed but he is on vacation, NP says, "we periodically phlebotomize him,not sure how much blood was removed but at least a unit". I am unable to get a stat CBC. My anesthesiologist is willing to do the case. I cancel the case, and reschedule for later in the week to get an accurate starting H/H. Am I being overly cautious?

Yes. However, better safe than sorry. Unless they removed 5 or more units he is unlikely to be anemic. And even if he was slightly anemic(10-12) he would need to lose probably at least a liter before he became symtomatic. Given young age and good health I foresee no problems.

 

[Psai]

Agree with choco. A unit should make his hgb about 15 or so which is just fine. Having a hgb that is too high can be detrimental, especially with increased risk of thrombosis.

 

[narcusprince]

Do the case. Sludging to the point of slowing cardiac output and thrombosis is high like hgb of 20. I would ask you are your concerns anemia or the erythrocytosis? Ultimately im sure the anesthesiologist did not really mind. If you are concerned and want to cancel as the surgeon go ahead. Especially if your concerned about delivery/uptake of oxygen at the surgical site.

 

[NITRAS]

This may be a dumb question from a non-surgical doc, but why would you be doing surgery in a place an unable to get at least an istat h/h?

Is this common?

 

[chocomorsel]

This may be a dumb question from a non-surgical doc, but why would you be doing surgery in a place an unable to get at least an istat h/h?

Is this common?

Common enough. Surgeons who have OR suites in their offices do this. Lots of plastics, dental, deem, etc.

 

[nofliesonme]

This may be a dumb question from a non-surgical doc, but why would you be doing surgery in a place an unable to get at least an istat h/h?

Is this common?

labs are close by stat H/H takes 3-4 hours

 

[nofliesonme]

Do the case. Sludging to the point of slowing cardiac output and thrombosis is high like hgb of 20. I would ask you are your concerns anemia or the erythrocytosis? Ultimately im sure the anesthesiologist did not really mind. If you are concerned and want to cancel as the surgeon go ahead. Especially if your concerned about delivery/uptake of oxygen at the surgical site.

my concern was not knowing how much blood was removed and what the starting hemoglobin is......obviously a large double mastectomy with liposuction can have a significant blood loss....patient also lives 3 hours away.....in a hospital, stat h/h and do the case.....office problems open a whole different can of worms

 

[coffeebythelake]

my concern was not knowing how much blood was removed and what the starting hemoglobin is......obviously a large double mastectomy with liposuction can have a significant blood loss....patient also lives 3 hours away.....in a hospital, stat h/h and do the case.....office problems open a whole different can of worms

I would assume Hgb would be normal or high-normal and go with it. Hematologist is not there to bleed the patient into anemia. You said otherwise pt was young and presumably otherwise healthy so I would only consider transfusion if Hgb dropped down to the 7 range. That's a lot of blood loss.

 

[vector2]

There is essentially a zero percent chance the hematologist phlebotomized him to a hgb under 12-13. The anesthesiologist is likely working under the assumption that if the patient is asymptomatic, has no med hx, and has good exercise tolerance then s/he would proceed even if the hgb was 10-11 considering that a healthy 20 something can tolerate a hgb of 5-7 all day long.

Unless you plan on bleeding the pt by about half their circulating volume during your procedure, you're being overly cautious. Keep in mind, you're paying your anesthesiologists not only to anesthetize your pts, but also for their expert pre-op medical judgement and risk stratification.

 

[IMGASMD]

my concern was not knowing how much blood was removed and what the starting hemoglobin is......obviously a large double mastectomy with liposuction can have a significant blood loss....patient also lives 3 hours away.....in a hospital, stat h/h and do the case.....office problems open a whole different can of worms

I don’t have much to add, just want to say I applaud your effort and due diligence. We’ve all encountered too many surgeons who will just go go and go. Not many will think out loud then cancel the case, especially bother to think about something that happens well (5 hours?) after surgery.....

 

[Ronin786]

72kg individual, 70cc/kg of blood volume = 5L of circulating blood volume.


Initial hemoglobin of 17.1 and assuming a transfusion threshold of 7 = ~3L of EBL to require a blood transfusion. Unless the phlebotomist moonlights as a vampire, you probably had quite the safety margin.

 

[narcusprince]

Its all about systems. I think a fair compromise send the h/h before surgery do the case and send one when you are closing, so its back before s/he goes home. I applaud you getting involved in the discussion.

 

[chocomorsel]

my concern was not knowing how much blood was removed and what the starting hemoglobin is......obviously a large double mastectomy with liposuction can have a significant blood loss....patient also lives 3 hours away.....in a hospital, stat h/h and do the case.....office problems open a whole different can of worms

Where have you been all my life?

 

[narcusprince]

Im no hematologist but a hgb of 17 is perfectly acceptable for a male. Or a woman without menses.

 

[anbuitachi]

Good surgeon . Always good to be cautious. Need more surgeons like you.

In this case I would have proceeded. You would have to bleed a lot to make this young patient unstable.

 

[coffeebythelake]

Good surgeon . Always good to be cautious. Need more surgeons like you.

I agree with this sentiment. There are way too many cavalier surgeons out there who just want to cut and who treat their patients like meat.

 

[dchz]

There is essentially a zero percent chance the hematologist phlebotomized him to a hgb under 12-13. The anesthesiologist is likely working under the assumption that if the patient is asymptomatic, has no med hx, and has good exercise tolerance then s/he would proceed even if the hgb was 10-11 considering that a healthy 20 something can tolerate a hgb of 5-7 all day long.

Unless you plan on bleeding the pt by about half their circulating volume during your procedure, you're being overly cautious. Keep in mind, you're paying your anesthesiologists not only to anesthetize your pts, but also for their expert pre-op medical judgement and risk stratification.

I was wondering if i was the only one that will look for every excuse possible not to transfuse this pt. Good to know I'm not alone.

with that said i'm also voting this as an extremely over cautious cancellation.

 

[Planktonmd]

Plastic surgeon here, I have tremendous respect for good anesthesiologists and learn from this board. I'd like to present a recent case....Patient is a 25 year old female to male transgender patient, 5'0, 160lbs, scheduled for bilateral mastectomy, bilateral nipple areola reconstruction and chest wall liposuction for July 1. Each breast resection will be over 800 grams, total liposuction aspirate estimated to be 500ml and the estimated operative time is 3 1/2 hours. Surgery is in an accredited office operatory. Patient is going home after surgery and lives 2 1/2 hours away. Patient gets 100mg testosterone weekly and has a pre-op Hgb. of 17.1 on 6/24. Morning of surgery patient says 3 days ago my hematologist did a phlebotomy. I call the hematologist, to find out how much blood has been removed but he is on vacation, NP says, "we periodically phlebotomize him,not sure how much blood was removed but at least a unit". I am unable to get a stat CBC. My anesthesiologist is willing to do the case. I cancel the case, and reschedule for later in the week to get an accurate starting H/H. Am I being overly cautious?

I admire your cautiousness and agree with your wise decision.
There is no need to proceed with this purely elective case if you have any doubts on your mind.

 

[adamkiewicz]

Just curious what the post op pain management plan for these type of cases?

Single shot bilateral paravertebral blocks with liposomal bupivacaine? Or just plain bupi. Then send them home.

I’ve seen some of these cases get admitted for pain control after surgery at an ASC (which is right next to the main hospital).

 

[Noyac]

I agree with everyone here, I would have proceeded with the case (no surprise I’m sure).

But I’m wondering why this pt has an elevated H/H? Is it the “T”? If not, I would work this up more but I’m sure the hematologist bas done this already. This should be right up their alley. So I guess it the “T”.

With that being said, there are professional cyclists dropping dead from elevated H/H’s. Too mush EPO.

A hub of 17 (hct 51) isn’t quite the level of these cyclists but I believe a Hct of 54 knocked off one not too long ago. I’m too lazy to check that statement at this time.

Go BLADE!!!

 

[2Fast2Des]

Couldn't you just dilute a little with some preemptive IV fluids if concerned about too high of H/H?

 

[Twiggidy]

my concern was not knowing how much blood was removed and what the starting hemoglobin is......obviously a large double mastectomy with liposuction can have a significant blood loss....patient also lives 3 hours away.....in a hospital, stat h/h and do the case.....office problems open a whole different can of worms

i agree with this rationale. you're in an office setting with limited resources. that's no place to take risks. Also, the case isn't urgent or emergent so if all the stars aren't aligning in this type of environment cancel until they align.

 

[Planktonmd]

I agree with everyone here, I would have proceeded with the case (no surprise I’m sure).

But I’m wondering why this pt has an elevated H/H? Is it the “T”? If not, I would work this up more but I’m sure the hematologist bas done this already. This should be right up their alley. So I guess it the “T”.

With that being said, there are professional cyclists dropping dead from elevated H/H’s. Too mush EPO.

A hub of 17 (hct 51) isn’t quite the level of these cyclists but I believe a Hct of 54 knocked off one not too long ago. I’m too lazy to check that statement at this time.

Go BLADE!!!

Since the patient is getting regular phlebotomies and is being managed by a hematologist you could probably assume that he has polycytemia vera.

 

[Mman]

Plastic surgeon here, I have tremendous respect for good anesthesiologists and learn from this board. I'd like to present a recent case....Patient is a 25 year old female to male transgender patient, 5'0, 160lbs, scheduled for bilateral mastectomy, bilateral nipple areola reconstruction and chest wall liposuction for July 1. Each breast resection will be over 800 grams, total liposuction aspirate estimated to be 500ml and the estimated operative time is 3 1/2 hours. Surgery is in an accredited office operatory. Patient is going home after surgery and lives 2 1/2 hours away. Patient gets 100mg testosterone weekly and has a pre-op Hgb. of 17.1 on 6/24. Morning of surgery patient says 3 days ago my hematologist did a phlebotomy. I call the hematologist, to find out how much blood has been removed but he is on vacation, NP says, "we periodically phlebotomize him,not sure how much blood was removed but at least a unit". I am unable to get a stat CBC. My anesthesiologist is willing to do the case. I cancel the case, and reschedule for later in the week to get an accurate starting H/H. Am I being overly cautious?

I applaud a surgeon that cares about their patient enough to cancel a case if they aren't comfortable. However I also question a surgeon that is willing to do a case in an office that they expect to last so long and potentially lose so much blood.

 

[nofliesonme]

update:............the high hgb. is secondary to chronic testosterone injection in this 4'9" FTM transgender patient, he has periodic phlebotomies, I did feel irked that no one considered telling the surgeon that 3 days before surgery a phlebotomy would be done... had H/H the day after cancellation, Hgb. 14.8, 3 days later surgery done......EBL per anesthesia 300ml., operating time 3 hours, liposuction aspirate 400ml, Right mastectomy 1574 grams, Left mastectomy 1584 grams.....an old surgical sayings come to mind....you make your reputation not by the great cases you do but the disasters you avoid.......

 

[nofliesonme]

Just curious what the post op pain management plan for these type of cases?

Single shot bilateral paravertebral blocks with liposomal bupivacaine? Or just plain bupi. Then send them home.

I’ve seen some of these cases get admitted for pain control after surgery at an ASC (which is right next to the main hospital).

i used to use pain pumps, and I have used Exparel....currently using lidocaine during case and marcaine at conclusion.

 

[nofliesonme]

I applaud a surgeon that cares about their patient enough to cancel a case if they aren't comfortable. However I also question a surgeon that is willing to do a case in an office that they expect to last so long and potentially lose so much blood.

I do cases like this routinely....the only lab I order pre-op is a CBC...I like to have an accurate H/H before I operate....

 

[nofliesonme]

Couldn't you just dilute a little with some preemptive IV fluids if concerned about too high of H/H?

I was not concerned that the Hgb. was too high....I was concerned because i did not know how much blood was removed and what the starting Hgb. would be

 

[Noyac]

I do cases like this routinely....the only lab I order pre-op is a CBC...I like to have an accurate H/H before I operate....

And that’s all you should be measuring unless you have a reason to measure others. Pan labs are not necessary for 90% of the cases done. The same goes for ECG’s.
Seriously, do you want to come start a practice in God’s country?

 

[Noyac]

I was not concerned that the Hgb. was too high....I was concerned because i did not know how much blood was removed and what the starting Hgb. would be

So some simple calculations can guide this for average adult female has 65ml/kg of blood. That means your pts blood volume is about 4700ml.
The “allowable blood loss” can be determined by:
ABL= EBV X (starting hct-ending hct)/starting hct. If you recall from medical training, hct = hgb x 3. Therefore your pt at a hgb of 17.1 would be a hct of 51.3
IE: ABL= 4700 x (51-35)/51
= 1,474 ml.
So the hematologist would have to remove 1/3 for his blood vol to get down to a hct of 35%. That’s a lot of blood.
But in this case 500ml removed would end up at a hct of 45. That’s pretty reasonable.

I know this is probably more than you wanted but it gives you an idea.

 

[UnoMas]

So some simple calculations can guide this for average adult female has 65ml/kg of blood. That means your pts blood volume is about 4700ml.
The “allowable blood loss” can be determined by:
ABL= EBV X (starting hct-ending hct)/starting hct. If you recall from medical training, hct = hgb x 3. Therefore your pt at a hgb of 17.1 would be a hct of 51.3
IE: ABL= 4700 x (51-35)/51
= 1,474 ml.
So the hematologist would have to remove 1/3 for his blood vol to get down to a hct of 35%. That’s a lot of blood.
But in this case 500ml removed would end up at a hct of 45. That’s pretty reasonable.

I know this is probably more than you wanted but it gives you an idea.

MS4 going into Anesthesiology lurking and learning from the masters here. Is there a reason why you choose 35 as your ending hct? Is there a commonly used final hct among anesthesiologists? The only paper I could find was published back in 1987 and it states 30% is acceptable for surgical patients

 

[vector2]

MS4 going into Anesthesiology lurking and learning from the masters here. Is there a reason why you choose 35 as your ending hct? Is there a commonly used final hct among anesthesiologists? The only paper I could find was published back in 1987 and it states 30% is acceptable for surgical patients

The numbers are relatively arbitrary and ultimately we should be treating the pt based on his particular symptomatology and comorbidities, but all the institutions where I've worked have used a hgb threshold of 7 for the average pt and 8 for those with significant ischemic heart disease / AS / LVH / post cardiac surgery etc.

https://www.ncbi.nlm.nih.gov/pubmed/27731885

 

[UnoMas]

The numbers are relatively arbitrary and ultimately we should be treating the pt based on his particular symptomatology and comorbidities, but all the institutions where I've worked have used a hgb threshold of 7 for the average pt and 8 for those with significant ischemic heart disease / AS / LVH / post cardiac surgery etc.

Transfusion thresholds and other strategies for guiding allogeneic red blood cell transfusion. - PubMed - NCBI

ah so the typical thresholds for transfusion still hold true. I was wondering if there's any secret Anesthesiologist's unwritten rule or something involved. Thanks doc!

 

[Noyac]

MS4 going into Anesthesiology lurking and learning from the masters here. Is there a reason why you choose 35 as your ending hct? Is there a commonly used final hct among anesthesiologists? The only paper I could find was published back in 1987 and it states 30% is acceptable for surgical patients

No reason. I just chose 35 since I would rather start with a hct of 35 than 30 or 25. It was just a “for example”.
No anesthesiologist would balk at taking an elective case to the OR with a hct of 35. Lots of room to work with.

Also, there is no commonly used hct. Every case is dependent on the pt and the surgery to be performed. For example, pts with ESRD are always anemic and because of this they to.erate much lo I don’t care if their hct is 28. But I do care if a normal 25 yo has a hct below 30 without a good explanation.

 

[Noyac]

ah so the typical thresholds for transfusion still hold true. I was wondering if there's any secret Anesthesiologist's unwritten rule or something involved. Thanks doc!

Vector is correct.
But I will add this. As anesthesiologists, we tend to focus on the intraoperative scene and forget about the post operative time. There was a time when I was really conservative about my transfusion practice. Something like vector described above. But then I noticed that surgeons would end up needing to transfuse on the floor just to get the pts up and moving. It is a bad setup to have a pt on the floor recovering from surgery that is too weak and tired to move.
Now I wait for the usual signs in the OR, like soft BP requiring more and more vaspressor support and increasing HR, decreased SATS( even if its well above 90%),etc. if that occurs at an HCT of 30 then I transfuse. The pts recover faster. Leave the hospital faster and have an overall better outcome IMO. I have rad most of the studies and this is my observation. That doesn’t mean I transfuse Willy Nilly. But I don’t with hold either.

 

[sigrhoillusion]

Vector is correct.
But I will add this. As anesthesiologists, we tend to focus on the intraoperative scene and forget about the post operative time. There was a time when I was really conservative about my transfusion practice. Something like vector described above. But then I noticed that surgeons would end up needing to transfuse on the floor just to get the pts up and moving. It is a bad setup to have a pt on the floor recovering from surgery that is too weak and tired to move.
Now I wait for the usual signs in the OR, like soft BP requiring more and more vaspressor support and increasing HR, decreased SATS( even if its well above 90%),etc. if that occurs at an HCT of 30 then I transfuse. The pts recover faster. Leave the hospital faster and have an overall better outcome IMO. I have rad most of the studies and this is my observation. That doesn’t mean I transfuse Willy Nilly. But I don’t with hold either.

I concur. I'm pretty strict with my transfusion thresholds. But just because a patient doesn't die because of not transfusing, doesn't mean that they might not benefit from a little of the red stuff.

 

[GravelRider]

Depends on the weather...sunny and nice means cancel. Rainy and cold means proceed.

Oh and definitely an a-line.

 

[UnoMas]

Thanks docs! Always lots to learn reading the Anesthesia and Critical Care forums

 

[deleted162650]

Seriously, do you want to come start a practice in God’s country?

You lookin’ for someone to help you complete your transition?

 

[Mman]

I do cases like this routinely....the only lab I order pre-op is a CBC...I like to have an accurate H/H before I operate....

plenty of people do stuff like this all the time. But when I review a case with a bad outcome on a several hour surgery with moderate expected blood loss in an office based setting, let's just say it doesn't tend to look good for the surgeon. And yes, most of the time nothing bad happens, though if you do it long enough you eventually see the bad outcomes.

 

[coffeebythelake]

I concur. I'm pretty strict with my transfusion thresholds. But just because a patient doesn't die because of not transfusing, doesn't mean that they might not benefit from a little of the red stuff.

Giving transfusions are not without risk. Aside from the usual things we think about, there is an increasing body of studies linking transfusions with immodulatory effects with associated morbidity and mortality.

I use 6-7 hgb as my usual threshold for healthy or, 8 for those with relevant significant comorbidities, and higher on a case by case basis. I try to be very conservative and only give blood if I felt absolutely needed. Some surgeons I've seen transfuse patients above 12 which is complete madness imo

 

[deleted171991]

Giving transfusions are not without risk. Aside from the usual things we think about, there is an increasing body of studies linking transfusions with immodulatory effects with associated morbidity and mortality.

+1. They should be called blood transplants.

Let's not mention the infectious risk for prions or stuff that we don't test for yet (see HIV and hepatitis in the past).

The younger the patient, the more I postpone blood products (including albumin).

 

[Psai]

Giving transfusions are not without risk. Aside from the usual things we think about, there is an increasing body of studies linking transfusions with immodulatory effects with associated morbidity and mortality.

I use 6-7 hgb as my usual threshold for healthy or, 8 for those with relevant significant comorbidities, and higher on a case by case basis. I try to be very conservative and only give blood if I felt absolutely needed. Some surgeons I've seen transfuse patients above 12 which is complete madness imo

I get the whole idea of keeping ahead of blood loss in a potentially bloody case but theres increasing literature about the downsides of transfusions. Hopkins has been running their one unit at a time campaign and not only has morbidity gone down, they have significant savings. It is 6 or 7 figures from what I recall from their recent paper.

 

[deleted87051]

What do you guys do for patients with significant polytrauma?

We’ve used to delay transfusion until hgb<8. Now we restrict crystalloid and resuscitate with whole blood from the start. At least in the short term the patients do much better.

 

[coffeebythelake]

What do you guys do for patients with significant polytrauma?

We’ve used to delay transfusion until hgb<8. Now we restrict crystalloid and resuscitate with whole blood from the start. At least in the short term the patients do much better.

Depends on where they are at. If beginning of case and u know pt going to bleed massively and abruptly then I am more liberal for fear of not being able to catch up. Immediate concerns of exsanguination trumps longer term risks in this case. And yes it can be very difficult to estimate blood losses in a polytrauma. If the bloodletting has slowed and case near conclusion then I check my labs to confirm needs and go back to my restrictive blood practice.

You use whole blood at your hospital???? Is this a common practice? We use component therapy.

 

[deleted87051]

Depends on where they are at. If beginning of case and u know pt going to bleed massively and abruptly then I am more liberal for fear of not being able to catch up. Immediate concerns of exsanguination trumps longer term risks in this case. And yes it can be very difficult to estimate blood losses in a polytrauma. If the bloodletting has slowed and case near conclusion then I check my labs to confirm needs and go back to my restrictive blood practice.

You use whole blood at your hospital???? Is this a common practice? We use component therapy.

We used to attempt to replicate whole blood with components. Now we have cold whole blood. Much simpler. Coming soon to a trauma center near you!