Pt with cad on placid for vaginal sling

[deleted682700]

Gynecologist wants to do sling procedure on 60 yr old with history of MI 3 yrs ago on plavix. Cardiac consult saw her and cleared her, but continued the plavix without writing as to why her thrombotic risk and risk of period mi is higher than the risk of bleeding.
Of course regional is out of the question.
I need further data including her ef? Any recent stress test?
If I do not have that info, I think I am just going to cancel the case. What do u guys do in such a situation? What should I do to legally protect myself?
Background info. Working in a small hospital where everyone is disgruntled and may even be the ones passing out the less optimal outcomes to lawyers.

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[Wiscoblue]

Does the pt have a stent?

 

[chocomorsel]

Find out her exercise capacity. If she is not obese, not a smoker, not diabetic, doesn't have vascular disease and good exercise tolerance I would be fine doing her as long as the gyn were OK with the bleeding risk, which really is your biggest problem if she is relatively healthy.

I have been seeing patients on Plavix for years after their MI/stent placement lately. Gotta talk to a cardiologist. I had one patient who stopped her plavix for 5 days, then accidentally took it the day before surgery and the orthopod didn't want to take the risk so cancelled the case. I doubt the surgeon in this case wants to do a case with a patient still on plavix so he/she will likely cancel it for you.

 

[deleted171991]

You need 7 days off Plavix, with cardiology blessing. I wouldn't stop an antiplatelet drug without the approval of its prescriber. Talking to the cardiologist is a great idea (might clear up a number of questions).

I wouldn't do the case on Plavix. If she starts bleeding, what a crapfest.

This is an elective surgery. As in all preventable risks should be avoided.

When off Plavix, I wouldn't bother getting more data than just the H&P and an EKG, unless her exercise capacity is low. If more than 4 METs and off Plavix, go to Surgery. This is a bread and butter GA-LMA case.

 

[chocomorsel]

What is the bleeding risk of a sling procedure? I don't remember much blood being involved, however, FFP is right. No need to invite back juju and since there is no reversal, both docs would be ****ed. Yeah, I take my previous statement back. Cancel it with plavix. Can't say I have ever done a case on plavix except maybe an EGD?

 

[Planktonmd]

I am not sure I understand your problem... you have a 60 y/o patient who apparently had an MI 3 years ago who is currently on Plavix, possibly because she has a DES or whatever the reason might be.
the surgeon is aware of Plavix and wants to proceed,
She is obviously asymptomatic and stable.
She is going to get a vaginal sling,,, which is a 5 minutes procedure... what's bothering you?

 

[Colba55o]

It sounds like the OP does not trust his colleagues. Are the cardiologist and GYN docs schmucks? If you think the clearance was bull**** and the GYN doc is clueless then OP has right to be concerned. Just because patient was cleared doesnt mean anesthesia wont also be named in a lawsuit if something happens.
cardiology clearance and surgeon "awareness" don't mean we have freedom to be careless propofol and sevo dispensaries.

I am not sure I understand your problem... you have a 60 y/o patient who apparently had an MI 3 years ago who is currently on Plavix, possibly because she has a DES or whatever the reason might be.
the surgeon is aware of Plavix and wants to proceed,
She is obviously asymptomatic and stable.
She is going to get a vaginal sling,,, which is a 5 minutes procedure... what's bothering you?

 

[Wiscoblue]

I would tell the patient and the surgeon that there is no anesthesia risk with plavix. If the surgeon wants to proceed with the case, knowing that she might bleed, that's the surgeon's problem. Why should I want to cancel the case?

 

[RxBoy]

I would tell the patient and the surgeon that there is no anesthesia risk with plavix. If the surgeon wants to proceed with the case, knowing that she might bleed, that's the surgeon's problem. Why should I want to cancel the case?

This.

And like PlanktonMD... I dont understand the issue? If surgeon is ok doing a case with pt with CAD + plavix, you should be happy. Ill take minor blood lose over an MI any day of the week.

 

[deleted682700]

Thanks for the input
Unless the cardiologist has clearly documented that she needs to be on plavix, and the reasons why he thinks that she should not come off the plavix, it indicates to me with limited info that the patient may be really sick cad wise. That said we do not have any cardiac lab or stunting in my small hospital. If it's a really risky case then this gynecologist has no bussiness doing it in small hospital.

Questionable surgeons in collusion with shady administrators think they can make all the money and delegate the risk to anesthesiologist. In q/a meetings I would be repeatedly asked why i even proceeded with the case. And in small hospitals getting blood and blood products will be a problem.

Damned if you do damned if u don't. I don't have any info and will state all that and educate the patient , document in the chart and cancel the case.

 

[deleted682700]

One of the obstetricians, was doing a bilateral tubal ligation on a obese patient and was having difficulty finding the tubes. He had troubled history. That day he cut the iliac artery. The general surgeon was kind enough to clamp the aorta and repair what he could and medic lighted out that patient. The board investigated that case 8 yrs ago, the obgyn lost his license. She is walking but she sued him.
The med board did their own investigation and was asking me why I didn't stop this from happenning? The legal people are in a different world. Every step of the way , patient was educated, lines places, blood products given and incubated to help in transport. She cam back with a walker several weeks later And thanked us.
Moral is yes bleeding I his problem until he hits a major one then it will my resuscitation problem

 

[chocomorsel]

Ok then, if you don't feel comfortable and think the surgeon is not good and might hit an artery or whatever and the patient will bleed like a stuck pig, cancel it. But it wouldn't be because of lack of an echo. You can order the patient to D/C the plavix yourself. Gosh it's been three years and from what I have read 2.5 years is more than enough in high risk for thrombus patient.
Moral, cancel if you are uncomfortable and document well your reason after speaking to the surgeon. I am sure you will get flack for it, but it's your license on the line.

Are you typing from your phone? Lots of tyos.

 

[deleted171991]

She is going to get a vaginal sling,,, which is a 5 minutes procedure... what's bothering you?

Probably because it's more like 50 minutes (where I work).

 

[deleted171991]

I would tell the patient and the surgeon that there is no anesthesia risk with plavix. If the surgeon wants to proceed with the case, knowing that she might bleed, that's the surgeon's problem. Why should I want to cancel the case?

Because, as Colba55o suggessted, any bad outcome becomes also your problem.

That's also why smart surgeons run away from patients with significant anesthetic risk, when they can.

 

[Ignatius J]

Do it. Next case.

 

[deleted682700]

What do big institutions do? Do they follow their cardiologist? Do they stop placid for 5 or 7 days. Do they have any recommendation for a small hospital without cath lab or stent facilities?

Sorry, auto correct is making all the typos

 

[bcat85]

Gynecologist wants to do sling procedure on 60 yr old with history of MI 3 yrs ago on plavix. Cardiac consult saw her and cleared her, but continued the plavix without writing as to why her thrombotic risk and risk of period mi is higher than the risk of bleeding.
Of course regional is out of the question.
I need further data including her ef? Any recent stress test?
If I do not have that info, I think I am just going to cancel the case. What do u guys do in such a situation? What should I do to legally protect myself?
Background info. Working in a small hospital where everyone is disgruntled and may even be the ones passing out the less optimal outcomes to lawyers.

This is a moderate risk procedure. If her functional status is ok and her surgeon is OK operating with her on plavix, there is no need for further testing. (Recognizing that keeping anyone on plavix for 3 years after a stent (presumably) is likely serious overkill). The cardiologist here is actually being much more conservative than the guidelines would suggest he should be.

At my hospital, the patient would likely just call the cardiologist, explain the situation, and have them stop the plavix for 7 days. Especially at 3 years out.

 

[pgg]

I need further data including her ef? Any recent stress test?
If I do not have that info, I think I am just going to cancel the case.

Why do you think you need a stress test or echo?

Don't stop the Plavix. Assuming she's 3 years out from being stented (you only said the MI was 3 years ago), the case can go. If the surgeon is OK with the surgical site bleeding risk, proceed. It's a bladder sling, not a craniotomy.

Background info. Working in a small hospital where everyone is disgruntled and may even be the ones passing out the less optimal outcomes to lawyers.

Also, life's too short to live and work with people like that. This is the second case in as many days where you've posted some really conservative (to the point of oddly weird) management based solely on your fear of litigation. If that place is really that toxic, with so many physicians who are so incompetent ... leave.

 

[deleted682700]

It's plain oversight after talking with the cardiologist. If only anesthesiologists weren't under the microscope for all and sundry, there may be a reason to throw caution and established dictum and proceed practically.