Radial A-line and Clopidogrel

[susruta]

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I had a case few weeks ago who was 1 week from acute MI and failed PCI, needing an Semi - emergency surgery.
Placed and A- line for the case. Post op pt developed hematoma when the line was pulled in the PACU. Now its going for review.
Normally I would not have placed the aline for this case.

Would it be considered a high risk procedure to place an Aline in this patient ?

 

[Wiscoblue]

So why are you to blame? This case absolutely needs an art line. The nurse who pulled it did a lousy job by not holding pressure.

 

[urge]

I had a case few weeks ago who was 1 week from acute MI and failed PCI, needing an Semi - emergency surgery.
Placed and A- line for the case. Post op pt developed hematoma when the line was pulled in the PACU. Now its going for review.
Normally I would not have placed the aline for this case.

Would it be considered a high risk procedure to place an Aline in this patient ?

A hematoma gets a case reviewed?

 

[psychbender]

Why the hell does that trigger a review? Lines of all sorts in patients on antiplatelet agents or other anticoagulants are at higher risk of hematoma formation, so the development of a hematoma should not surprise anybody.

If I reviewed the case, it'd be, "a-line was indicated, **** happens, standard of care met, next case."

 

[Arch Guillotti]

I had a case few weeks ago who was 1 week from acute MI and failed PCI, needing an Semi - emergency surgery.
Placed and A- line for the case. Post op pt developed hematoma when the line was pulled in the PACU. Now its going for review.
Normally I would not have placed the aline for this case.

Would it be considered a high risk procedure to place an Aline in this patient ?

Bogus review.

Who "reported" it for review anyway?

 

[chfo]

The review is probably for the nurse who pulled it. Or the physician who wanted the arterial line pulled, and didn't give instructions to hold pressure for however long you should while on plavix. 30min? 60min?

 

[SouthSideSteve]

I do Alines all the time on anticoagulated pts. The nurse screwed the pooch here, not you. Waste of time and energy to review this.

 

[seinfeld]

I do aline, central lines and any procedure that is indicated no matter the anticoagulation status. K 8.1 with t wave changes, INR 12 while on effient gets a temorpary dialysis line, no change in my thoughts (maybe i would order KCENTRA or other prothrombin complex but only after i see how much bleeding was taking place). Anyone who has done liver transplants knows that when a patient needs IV access and monitoring they get!!

The review should be for the nurse or the MD who ordered it pulled.

 

[BLADEMDA]

1. Kcentra is dosed according to Factor IX potency and is individualized based on the patient's baseline International Normalized Ratio (INR) and body weight. The cost of Kcentra is $1.27 per unit; a single dose of Kcentra for an 80 kg patient costs $5,080.

 

[deleted171991]

It's a compressible site, hence there should be no issue with anticoagulation. The error was not holding compression long enough, after removal.

 

[urge]

1. Kcentra is dosed according to Factor IX potency and is individualized based on the patient's baseline International Normalized Ratio (INR) and body weight. The cost of Kcentra is $1.27 per unit; a single dose of Kcentra for an 80 kg patient costs $5,080.

How many bags of FFP does that dose of kcentra save you? FFP is not cheap either, ~300/bag.

 

[wickedskillz]

Agree with above. Placed an art-line on a hemophiliac hep C liver failure = 0 working clotting factors who had a ruptured esophagel varices once. blood shot about 10 feet and splattered on the wall. you gotta do what you gotta do. placing art-line in someone so recent post-MI falls under "you gotta do"

 

[Planktonmd]

1. Kcentra is dosed according to Factor IX potency and is individualized based on the patient's baseline International Normalized Ratio (INR) and body weight. The cost of Kcentra is $1.27 per unit; a single dose of Kcentra for an 80 kg patient costs $5,080.

Another outrageously expensive product that will never find a real indication.

 

[Planktonmd]

How many bags of FFP does that dose of kcentra save you? FFP is not cheap either, ~300/bag.

If there is a place for Kcentra it might be in attempting to reverse Warfarin for an emergency surgery or acute bleeding in a patient who will not be able to handle the volume of FFP required.
This is where they need to focus their marketing.

 

[DoctwoB]

If there is a place for Kcentra it might be in attempting to reverse Warfarin for an emergency surgery or acute bleeding in a patient who will not be able to handle the volume of FFP required.
This is where they need to focus their marketing.

We use it in trauma all the time. Most common reason is for rapid warfarin reversal in patients who can't tolerate large volumes (as you mentioned), usually old folks with head bleeds. Second is off label use for reversal of rivaroxaban and other factor 10 inhibitors in head bleeds and unstable patients. Some data to suggest it is effective, but this use will go away when factor 10 inhibitor reversal agents become available.

 

[deleted682700]

I learnt my MOCA minute here about kcentra. Does that count?
Tx

 

[deleted59964]

don't interventional cardiologists stick the radial or femoral arteries of patients on clopidogrel every day?

 

[wickedskillz]

Can't find the paper, but I read one about deletrious effects of under-reversing Coumadin and anti-coagulation in urgent cases, and how PCC is under-utilized for this purpose. The one time I used PCC was for a STICU patient needing a VATS for empyema (/hemothorax) who still had an INR of 2.6 despite 6U of FFP over 12 hours or so

 

[Twiggidy]

don't interventional cardiologists stick the radial or femoral arteries of patients on clopidogrel every day?

oh man….that avi tho…🙂

 

[deleted171991]

don't interventional cardiologists stick the radial or femoral arteries of patients on clopidogrel every day?

I remember how, in residency, the neurointerventional fellow would hold pressure for 15-20 minutes on the clock, at the end of each procedure. I have never seen a nurse do that. 😉