preop stent case

[Mman]

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@Mman, you're preaching to the choir. In my view, the future role of anesthesiologists will be strongly related to facilitating the surgeons' job everywhere, pre-, intra- and postop, much more than today. The surgeons will deal only with the surgical issues, which is less than 50% of what they do nowadays. It's not something I like, but it's one of the reasons I did CCM. The present problem is that neither surgeons nor AMCs are being paid for optimizing patients for anesthesia, hence neither of them care; as long as the surgery is not postponed (which they insist upon), it's not their careers and not their malpractice history.

But that's why we need as a specialty to get out in front on things like bundled payments. Make sure we are getting paid for our contribution to those things. We've used shared savings models whereby we can reduce the cost of preop testing but in exchange for that we get to keep some of the money that we save, hence we get paid for helping make their preop workup more efficient. But you have to work with the people paying the bills (insurers) to set that up.

 

[Scotty_G]

I know this could not work in most of the places you work but at my hosp (small comm) the on call attn calls all of the Main OR patients the day before surgery. This is already after they may have come for PAT's etc. The patient's in the community appreciate the phonecall and sometimes we catch something or learn something new that slipped through the cracks.

 

[deleted171991]

I know this could not work in most of the places you work but at my hosp (small comm) the on call attn calls all of the Main OR patients the day before surgery. This is already after they may have come for PAT's etc. The patient's in the community appreciate the phonecall and sometimes we catch something or learn something new that slipped through the cracks.

Only anesthesiologists would agree to something like that. Imagine the on-call surgeon calling all the patients for the next day. Yeah, sure!

 

[facted]

They ended up getting the cardiologist on the phone and had a conference call in the Preop cubical with the patient, pt family, surgeon, anesthesiologist, and cardiologist. It would've been interesting to hear the dynamics of the conversation but the end result was the cardiologist documented the surgery would be of minimal risk if the patient were to be plavix loaded and aspirin loaded prior to proceeding. Thus the case went forward (!) after these loads and a dense interscalene block (!). What do you think of this plan? Will the load likely work? When do periop MIs usually happen - intraop, post op, etc? Is an interscalene enough to cover a biceps repair under Mac?

Like a couple of you mentioned I wouldn't do it even if the patient had continued his antiplatelets without the ability to have a STEMI to needle time of 30 minutes. Do you all even allow patients with a history of CAD to come to an ASC? What is your line in the sand for telling a surgeon "no this patients CAD is too bad for outpatient surgery"?

This is a joke. 2016 ACC/AHA guidelines: http://content.onlinejacc.org/article.aspx?articleid=2507082. Page 22 of the PDF if you open up the guidelines.

In relation to surgical timing after PCI:
"On the basis of these considerations, the prior Class I recommendation that elective noncardiac surgery in patients treated with DES be delayed 1 year (15) has been modified to “optimally at least 6 months.” Similarly, the prior Class IIb recommendation that elective noncardiac surgery in patients treated with DES may be considered after 180 days (15) has been modified to “after 3 months.”

There are also guidelines higher up in the article discussing anticoagulation. Timeline depends partly on the initial indication for PCI (ACS vs SIHD) but suffice to say, with a DES, you're looking at DAPT for min 6 months and longer if ACS is involved.

I'm always amazed at how cardiologists either don't know, or totally ignore their own literature. I guarantee you, however, that a jury will not ignore this if this patient developed an MI on the table regardless of how badly he or the surgeon wanted to proceed. And in an Ambi center?!?! Cath lab available or not, this case is cancelled, but Ambi center....!!!!!

 

[facted]

Concerning anticoagulation, the current ASRA guidelines don't view peripheral nerve blocks any different than neuraxial blocks. In essence, they don't recommend PNBs in patients who've taken clopidogrel within the last 7 days. I don't fully agree with that, but were something to go wrong there'd be a line of expert witnesses there to say an ISB shouldn't have been done.

I believe this is actually incorrect. Per the ASRA guideline paper (http://journals.lww.com/rapm/Fullte...l_Anesthesia_in_the_Patient_Receiving.13.aspx)

"In addition, hemorrhagic complications after the deep plexus/peripheral techniques (eg, lumbar sympathetic, lumbar plexus, and paravertebral), particularly in the presence of antithrombotic therapy, are often serious and a source of major patient morbidity. Although needle/or catheter placement was described as difficult, there is often no evidence of vessel trauma (including the patient death from massive bleeding).
11.0 Anesthetic Management of the Patient Undergoing Plexus or Peripheral Block
11.1 For patients undergoing deep plexus or peripheral block, we recommend that recommendations regarding neuraxial techniques be similarly applied (Grade 1C)."

Note the mention of "deep" block. In addition, the position paper discusses the lack of hematoma issues with superficial PNB's in the paragraphs above this. They are making a clear delineation between non-compressible deep blocks and more superficial blocks like supra/interscalene, femoral, etc..

In my regional fellowship and my years of PP after, we've been doing superficial PNB's on AC patients routinely with no issue.

 

[psychbender]

They say "deep plexus or PERIPHERAL block." For nearly everyone in the medical world interpreting that guideline, it means PNBs are treated the same as neuraxial. If they wanted to separate out peripheral as ok, then they should have written that sentence to clearly specify that. I, too, have done plenty of peripheral blocks on anticoagulated patients safely. However, that's because I had a clear benefit for my little risk, and I practice in a relatively safe malpractice setting (military).

 

[facted]

They say "deep plexus or PERIPHERAL block." For nearly everyone in the medical world interpreting that guideline, it means PNBs are treated the same as neuraxial. If they wanted to separate out peripheral as ok, then they should have written that sentence to clearly specify that. I, too, have done plenty of peripheral blocks on anticoagulated patients safely. However, that's because I had a clear benefit for my little risk, and I practice in a relatively safe malpractice setting (military).

Per the position paper right before the recommendation is made:

" In addition, hemorrhagic complications after the deep plexus/peripheral techniques (eg, lumbar sympathetic, lumbar plexus, and paravertebral), particularly in the presence of antithrombotic therapy, are often serious and a source of major patient morbidity."

The blocks they are discussing in the recommendation are delineated. There is no mention of superficial block. I guess the recommendation sentence is grammatically vague, but they discuss in depth, above the recommendation, that the morbidity is really for deep blocks.

 

[Ignatius J]

This is easy. He didn't follow up with his cardiologist. For whatever reason, surgeons think/know that the cardiologist carries legal implication. Can't tell you how often I get "don't worry, cardiology cleared him" or "I know you will do it, but I would like cardiology to stop by first".

So I would just say to the surgeon that he failed proper follow-up and you are happy to do the case after he sees him because you don't want to risk either of your rear ends. This is a common theme and as long as you know how to phrase and work it almost every surgeon I know finds it reasonable.