Preoperative PE

[BobLoblaw78]

I had a patient scheduled for I&D of a hematoma with a h/o PE 3 weeks ago, afib, HTN, IDDM, chronic kidney disease stage 3, morbid obesity, and pancreatitis 2 weeks ago. I canceled the case for further evaluation and work-up once the patient comes in for preop. I can't believe that surgeon tried to sneak this one through! I would like to determine if right side of the heart is managing okay. I am wanting troponin, NT-proBNP, ECG, coags, CBC, CMP, lipase. Was also considering followup TTE as the one 3 weeks ago was without abnormalities, strain, or RWMA. EF=60%. Surgeon will likely request general anesthesia.

Too cautious? Let me know your take and what you think. I think that for an elective case and h/o PE alone, that the case should not go for 3 months. Also would consider CT to rule out residual or recurrence of PE in addition to above workup. MAC would be more reasonable, but still have difficulty. Still not worth it though to me. No IR if PE develops and patient becomes unstable. Also, would have bridging therapy in this patients case. Surprisingly, I don't recall much on this issue that is set in stone. Am I missing certain guidelines, etc? Thanks!

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[narcotics999]

I/D hematoma elective? The case needs to be done urgently or semi-urgently. What do you expect to change with the full workup?

 

[deleted875186]

Can the case be done on anticoagulation? If yes, then I would think just proceed. If not, then I think the case needs to be delayed.

The heart was functioning well at the time of the PE, so it probably is still functioning well. I would probably take a history and ensure the patient is getting better. The bio markers would be helpful if downtrending to tell you he’s getting better. I think if he is morbidl obese, now with PE, he probably has pHTN that will not tolerate MAC very well. An the surgeon do this under local anesthesia or a block?

 

[psychbender]

Where is the hematoma, and why does he need to I&D? PE without hemodynamic derangement or RV strain at time of diagnosis, on anticoagulation since then, I don't see any big reason to delay. For peace of mind, I might grab a probe and take a quick look myself in holding, but you haven't presented any reason that I can see to delay the case.

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[AdmiralChz]

Ready yourself for the “patient is considered moderate risk with no modifiable risk factors currently present and is considered clear for surgery” note from cardiology. We get that all the time. I don’t think you need all those labs - troponin? Think there’s active ischemia going on? CMP/lipase - how would that impact your care?

Where is the I&D? In a location that would be amenable to heavy local, minimal anesthesia? Agree that if it’s urgent you won’t have time to screw around.

Also if the TTE at the time of the PE (and later) showed no indicators of cardiac compromise then you are in a reasonable place. Given the info you’ve presented I’m not sure I would have delayed the case myself...

 

[anbuitachi]

Probably would have proceeded

 

[Southpaw]

What led to PE diagnosis? Is the patient anticoagulated? Are they symptomatic? What was your conversation with the surgeon? How urgent is the case? What was your conversation with the patient?

I ask the questions because there’s a decent chance that you gain nothing by delaying.

 

[sethco]

You want to delay an I+D for 3 months?

 

[deleted162650]

I ask the questions because there’s a decent chance that you gain nothing by delaying.

That’s not true. You gain one very irritated surgeon.

 

[Psai]

Where is the hematoma and why does it need to be drained? The patient has at least two reasons to be on anticoagulation and will either bleed or clot. They are also likely going to be hemodynamically unstable since they have ckd on top of the dm. Is the pancreatitis resolved or are they third spacing like a madman? Sounds like a crappy case.

 

[Arch Guillotti]

They are also likely going to be hemodynamically unstable since they have ckd on top of the dm.

??? The listed comordidities are a dime a dozen.

 

[Psai]

If you can't tell that this isn't your run of the mill case, I'm not sure how to help you.

Why does this hematoma need to be drained? If it needs to be drained, why can't it be done by IR under local?

 

[nimbus]

Not all PE’s are the same.

If he’s not dyspneic and can walk down the hall of the hospital, I would have proceeded.

If his HR is 140 and his RA sat is 90% I would want an echo and it would have to be an emergency.

 

[Arch Guillotti]

If you can't tell that this isn't your run of the mill case, I'm not sure how to help you.

Why does this hematoma need to be drained? If it needs to be drained, why can't it be done by IR under local?

lol if you can’t manage a case like this and are trying to punt to IR you are going to have a tough time in private practice. This case has generated an interesting discussion but the case itself is a piece of cake compared to disasters that some of us see on a regular basis.

 

[Arch Guillotti]

If you can't tell that this isn't your run of the mill case, I'm not sure how to help you.

Why does this hematoma need to be drained? If it needs to be drained, why can't it be done by IR under local?

Why is the patient likely to be “hemodynamically unstable”? Because they have a bunch of medical problems?

 

[Twiggidy]

Not all PE’s are the same.

If he’s not dyspneic and can walk down the hall of the hospital, I would have proceeded.

If his HR is 140 and his RA sat is 90% I would want an echo and it would have to be an emergency.

Exactly. There's your stress test.

 

[Twiggidy]

The H/P is stressful but there's still missing info
Current vitals?
Is he on the floor, in the ICU, or walking in from the street?
Where's the hematoma?
How does the patient "look"?

The moral is, that many patients may sound like a disaster, but actually pass the "eye test". As patients get older and sicker, you have to know how to handle these type of multiple medical problem patients or you may find yourself cancelling alot of cases and as @SaltyDog said, you'll have an irritated surgeon.

 

[Ronin786]

I don't see any reason to delay this case. A full workup isn't going to show you anything that hasn't killed this patient in the past month. Even if she wanted her knee replaced I don't see any reason to cancel.

 

[Ronin786]

I don't see any reason to delay this case. A full workup isn't going to show you anything that hasn't killed this patient in the past month. Even if she wanted her knee replaced I don't see any reason to cancel.

 

[deleted875186]

I don't see any reason to delay this case. A full workup isn't going to show you anything that hasn't killed this patient in the past month. Even if she wanted her knee replaced I don't see any reason to cancel.

I disagree, there is excellent reason to delay a knee replacement or any other elective surgery because it will require stopping anticoagulation, surgical stress and hypercoaguability, and an unnecessary risk of further clot burden in the lungs.

If the patients heart was fine at the time of the PE and they are doing fine now, the only real discussion is if the timing of the surgery outweighs the risk of being off anticoagulation for the surgery.

Although a small PE doesn’t mean the patient is very sick, I think some of he previous posters have underestimated the severity of how risky it could be to come off anticoagulation so soon after a VTE.

 

[fakin' the funk]

. They are also likely going to be hemodynamically unstable since they have ckd on top of the dm.

What in the what now

 

[fakin' the funk]

I would like to determine if right side of the heart is managing okay. I am wanting troponin, NT-proBNP, ECG, coags, CBC, CMP, lipase. Was also considering followup TTE as the one 3 weeks ago was without abnormalities, strain, or RWMA. EF=60%.

1) ask patient what they can do
2) I don't think you can interpret all those tests you want
3) what changed in the last 3 weeks?

 

[Mman]

if someone had a PE a couple weeks ago, I think my only questions relate to current hemodynamic stability and oxygenation. If the PE is significant enough to be causing a major impairment of cardiac filling, you should probably notice it in their vital signs and/or ability to have any exercise tolerance. And slapping a pulse ox on their finger will probably let you know if it is causing significant impairment in gas exchange, or if you are worried just check an ABG.

 

[Psai]

It's not about getting the patient through the case. It's about the postoperative complications that will likely occur in this patient. CKD, likely leaking proteins out of their urine affecting their coagulopathy. You'll be holding the ac they are almost certainly on. They are more coagulopathic due to the stresses of surgery and anesthesia. We don't know the size of the PE or why it happened, what will happen if the clot burden increases? Do they have a bunch of LE DVTs? Why do they have CKD? If it's from the diabetes and other comorbidities, do they have autonomic neuropathy that will cause crazy swings in the blood pressure during the case? I don't think the workup will help but I do think that we don't have enough information and this case is not as straightforward as you guys are making it out to be.

Maybe I'm biased but I saw almost this exact patient end up in the ICU, limp their way through the OR and I watched them code in the ICU the next day. This patient may be a ticking time bomb.

 

[coffeebythelake]

i think for this particular surgical procedure it would not be unreasonable to proceed assuming patient looked otherwise okay and functional capacity is at baseline. your main concern is the h/o PE 3 weeks ago. as mentioned before a PE can be tiny and hemodynamically significant, or they can be massive. an I&D is relatively minor and unlikely to cause a significant inflammatory response perioperatively. I would be much more concerned if it was a larger surgery or if they plan to use TXA or thrombin gel etc

 

[anbuitachi]

It's not about getting the patient through the case. It's about the postoperative complications that will likely occur in this patient. CKD, likely leaking proteins out of their urine affecting their coagulopathy. You'll be holding the ac they are almost certainly on. They are more coagulopathic due to the stresses of surgery and anesthesia. We don't know the size of the PE or why it happened, what will happen if the clot burden increases? Do they have a bunch of LE DVTs? Why do they have CKD? If it's from the diabetes and other comorbidities, do they have autonomic neuropathy that will cause crazy swings in the blood pressure during the case? I don't think the workup will help but I do think that we don't have enough information and this case is not as straightforward as you guys are making it out to be.

Maybe I'm biased but I saw almost this exact patient end up in the ICU, limp their way through the OR and I watched them code in the ICU the next day. This patient may be a ticking time bomb.

or the patient may not. this patient is unlikely to have a good outcome in the long run regardless of doing the case now or doing it in 3 months.

in terms of AC, can transition to heparin, pause for a few hours, do the case, and restart it after surgery.

 

[UscGhost]

Delaying the case poses a risk for further hematoma expansion..infection..etc.

Do the case. Run it by the primary doc to determine what anticoagulation they want since they will manage postop

 

[Mman]

It's not about getting the patient through the case. It's about the postoperative complications that will likely occur in this patient. CKD, likely leaking proteins out of their urine affecting their coagulopathy. You'll be holding the ac they are almost certainly on. They are more coagulopathic due to the stresses of surgery and anesthesia. We don't know the size of the PE or why it happened, what will happen if the clot burden increases? Do they have a bunch of LE DVTs? Why do they have CKD? If it's from the diabetes and other comorbidities, do they have autonomic neuropathy that will cause crazy swings in the blood pressure during the case? I don't think the workup will help but I do think that we don't have enough information and this case is not as straightforward as you guys are making it out to be.

Maybe I'm biased but I saw almost this exact patient end up in the ICU, limp their way through the OR and I watched them code in the ICU the next day. This patient may be a ticking time bomb.

Sure, but this isn't an elective case.

 

[Psai]

Sure, but this isn't an elective case.

How did you determine that?

 

[Hamhock]

I had a patient scheduled for I&D of a hematoma with a h/o PE 3 weeks ago, afib, HTN, IDDM, chronic kidney disease stage 3, morbid obesity, and pancreatitis 2 weeks ago. I canceled the case for further evaluation and work-up once the patient comes in for preop. I would like to determine if right side of the heart is managing okay. I am wanting lipase.
!

Lipase. Definitely the lipase first...and lipase q2h x 12 post-operatively.

The orginal post seems very trollish to me...or maybe the OP was trying to be funny. I read through all the responses and then went back and read the original post...and still thought: WTF!?!

HH

 

[Mman]

How did you determine that?

hematomas in anticoagulated patients that require evacuation aren't elective almost by definition

 

[Southpaw]

It's not about getting the patient through the case. It's about the postoperative complications that will likely occur in this patient. CKD, likely leaking proteins out of their urine affecting their coagulopathy. You'll be holding the ac they are almost certainly on. They are more coagulopathic due to the stresses of surgery and anesthesia. We don't know the size of the PE or why it happened, what will happen if the clot burden increases? Do they have a bunch of LE DVTs? Why do they have CKD? If it's from the diabetes and other comorbidities, do they have autonomic neuropathy that will cause crazy swings in the blood pressure during the case? I don't think the workup will help but I do think that we don't have enough information and this case is not as straightforward as you guys are making it out to be.

Maybe I'm biased but I saw almost this exact patient end up in the ICU, limp their way through the OR and I watched them code in the ICU the next day. This patient may be a ticking time bomb.

That's a reasonable board answer. However, the reality in private practice is one of two things:

1) the surgeon is reasonable --> the patient is anticoagulated and stable, and the surgeon who is very good and very fast is concerned about the hematoma worsening and/or it's infected and likely to make the patient sicker than they already are.

2) the surgeon is piss poor --> the patient is knocking on death's door with regards to their PE and they have other ongoing issues requiring ICU care and multiple pressors.

I've never personally witnessed #2 but I know that it's out there. With regard to #1, which is what I always deal with, we are proceeding to the OR for the 10 minute case.

 

[Arch Guillotti]

Was also considering followup TTE as the one 3 weeks ago was without abnormalities, strain, or RWMA. EF=60%. Surgeon will likely request general anesthesia.

Why are you getting another echo if the last one was normal?

 

[okayplayer]

Why are you getting another echo if the last one was normal?

Because it will take long enough to come back that the case will go to a different anesthesiologist.

 

[dannyboy1]

Less prop, more roc, same tube....

 

[Arch Guillotti]

Because it will take long enough to come back that the case will go to a different anesthesiologist.

Exactly!

Although it sounds like the surgeon sent this patient in to be seen ahead of time.

 

[BobLoblaw78]

The patient was to be first case on Monday without any labs, etc added to the schedule late Friday without consult, call, or heads up. Reviewed the cases for Monday and found it. Couldn't get patient to come in or answer at that point and still haven't heard from them. Surgeon was already gone and unavailable regarding discussion of anticoagulation and case. Local would be out of the question for his cases. I did neglect to state that it was an abdominal wall hematoma from lovenox injection 2-3 weeks ago (very elective). Sedation level needed for this surgeon is always twice as much or more than the average surgeon (general for vasectomy). Unfortunately, I have not laid eyes on patient even still because I expected them to show up this morning anyway.

Lipase was wanted to show resolution/cooling off of pancreatitis a couple weeks ago and to make sure the abdominal pain she is having is not recurrent/chronic pancreatitis. Putting on a TTE preop is not a big deal.

I obviously was getting overly concerned and appreciate the feedback. I was just worried about putting off the case without being able to see the patient first and having just reason. Usually, will just have them come in for the case on Monday and use that as preop time because I essentially never cancel. But she seemed to have too many extras. I'll update when I do lay eyes on her.

 

[BobLoblaw78]

Patient was less than 4 METS. Had already stopped Xarelto. Saturation on RA was 95%. Large 18 cm hematoma with bruising. No RWMA and good systolic function. Looks about what you would expect, but not as bad as you would fear. Had her take one dose of xarelto today and will hold for tomorrow until after surgery. She was consented for MAC and will proceed with the case tomorrow. Thanks again.

 

[Twiggidy]

Less prop, more roc, same tube....

Renal insufficiency....so how about less prop, adequate cisatracurium, same tube

 

[Psai]

Renal insufficiency....so how about less prop, adequate cisatracurium, same tube

Renal insufficiency isn't a reason to avoid roc. It's only 30% renally metabolized. I use it for renal transplants.

 

[coffeebythelake]

Renal insufficiency isn't a reason to avoid roc. It's only 30% renally metabolized. I use it for renal transplants.

I think less than 30% renal

 

[Twiggidy]

Renal insufficiency isn't a reason to avoid roc. It's only 30% renally metabolized. I use it for renal transplants.

That's great. I still would choose cis over roc for a renal insufficiency patient. My chances for problems in an already problem patient are less.

 

[coffeebythelake]

What do u guys think about sugammadex for kidney txp cases?

 

[Mman]

What do u guys think about sugammadex for kidney txp cases?

Manufacturer claims you need a special dialysis to remove the molecule if the kidneys aren't functioning. I guess if you are reasonably sure the new kidney will work it shouldn't be an issue.

 

[coffeebythelake]

special dialysis?! i was under impression that 3x dialysis sessions removes essentially all sugammadex molecules.

other..separate question is... what is the harm in having sugammadex sit in the blood stream for so long? to my knowledge there has not been any harm documented

 

[Mman]

special dialysis?! i was under impression that 3x dialysis sessions removes essentially all sugammadex molecules.

other..separate question is... what is the harm in having sugammadex sit in the blood stream for so long? to my knowledge there has not been any harm documented

I confess to knowing nothing about how it gets removed, but they apparently have special instructions for nephrologists to remove it and suggested we inform them if a dialysis patient has received it so they can act accordingly.

 

[Ronin786]

I confess to knowing nothing about how it gets removed, but they apparently have special instructions for nephrologists to remove it and suggested we inform them if a dialysis patient has received it so they can act accordingly.

Interesting that your rep told you that. In speaking with them personally, they say there's a higher risk for bradycardia but that's about it.

 

[Twiggidy]

special dialysis?! i was under impression that 3x dialysis sessions removes essentially all sugammadex molecules.

other..separate question is... what is the harm in having sugammadex sit in the blood stream for so long? to my knowledge there has not been any harm documented

More reasons why I'm using Nimbex. Let what part of the body that is still working do it's thing