Rotator cuff repair that is a bit unusual.

[sevoflurane]

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This was my first case last Friday.

67 y/o obese female presents to the outpatient side for rotator cuff repair. Pmhx: DM, Obesity, Smoker. I go into bay #5 and do my focused H&P. I discover she had a DES placed 6 mo. ago. I ask her if her orthopod knows this. She says yes. Hgb 12 and platelets are 242.

How do you proceed and what info do you want?

 

[Arch Guillotti]

Yeah but does the orthopod care?

This was my first case last Friday.

67 y/o obese female presents to the outpatient side for rotator cuff repair. Pmhx: DM, Obesity, Smoker. I go into bay #5 and do my focused H&P. I discover she had a DES placed 6 mo. ago. I ask her if her orthopod knows this. She says yes. Hgb 12 and platelets are 242.

How do you proceed and what info do you want?

 

[deleted126335]

This was my first case last Friday.

67 y/o obese female presents to the outpatient side for rotator cuff repair. Pmhx: DM, Obesity, Smoker. I go into bay #5 and do my focused H&P. I discover she had a DES placed 6 mo. ago. I ask her if her orthopod knows this. She says yes. Hgb 12 and platelets are 242.

How do you proceed and what info do you want?

Meds? Last dose? Is orthopod aware of anti anticoagulants they may or may not be taking? cardiac testing results would be nice. Any cardiac sx since stent placement? does cardiologist know about surgery?

 

[scudrunner]

Is this a bloody surgery?

Has the pt been compliant with effient (or other) therapy?

 

[sevoflurane]

She took her plavix this a.m. (thankfully) along with the rest of her meds.

 

[deleted126335]

She took her plavix this a.m. (thankfully) along with the rest of her meds.

1. Gently inform/educate orthopod about plavix.
2. Phone call to cardiologist if cardiol not aware.

plan to be determined based on the results of those conversations.

 

[sevoflurane]

Meds? Last dose? Is orthopod aware of anti anticoagulants they may or may not be taking? cardiac testing results would be nice. Any cardiac sx since stent placement? does cardiologist know about surgery?

So... after I interview her I tell her there is a good chance we are going to cancel the case. She tears up and starts talking about how bad her pain is. I step out.

I speak to the orthopod and he says that she has severe pain and understands that there is a chance of bleeding that may require blood products. They've had a long discussion about her surgery and she wishes to proceed.

Orthopod says that Cards won't take her off plavix because she had a high grade LAD stent placed.

She has had no symptoms since her stent was placed 6 mo. ago.

 

[deleted126335]

So... after I interview her I tell her there is a good chance we are going to cancel the case. She tears up and starts talking about how bad her pain is. I step out.

I speak to the orthopod and he says that she has severe pain and understands that there is a chance of bleeding that may require blood products. They’ve had a long discussion about her surgery and she wishes to proceed.

Orthopod says that Cards won’t take her off plavix because she had a high grade LAD stent placed.

She has had so symptoms since her stent was placed 6 mo. ago.

Inform and document. Do the case. No block (reasonable to disagree on this one). Favorite betabolcker based hemodynamically stable regimen. Special attention to ekg placement. Routine monitors.

 

[sevoflurane]

I engage in the plavix conversation with orthopod while nurses track down cards consult (I’m a little annoyed it wasn’t in her chart to begin with).

Orthopod starts quoting european studies about total joints being done with coumadin on board with no post-op complications.

I ask him how invasive this repair is going to be... he says "I’ll be in and out in about 20 minutes. Small tear... nothing major".

Cards consult arrives and confirms LAD placement of stent and no symptoms. Cards says “she’s cleared for surgery”

 

[pd4emergence]

This was my first case last Friday.

67 y/o obese female presents to the outpatient side for rotator cuff repair. Pmhx: DM, Obesity, Smoker. I go into bay #5 and do my focused H&P. I discover she had a DES placed 6 mo. ago. I ask her if her orthopod knows this. She says yes. Hgb 12 and platelets are 242.

How do you proceed and what info do you want?

I usually try to wait a year for elective cases that need to come off their plavix for said procedure. Question is whether it's truly elective. Is she in debilitating pain? If not I think she should go see her cardiologist for guidance on when he or she feels comfortable with her being having this done. Also I think some guidance regarding her plavix management is needed. If she is dying from pain, I think a call to her cardiologist and a discussion with the orthopod is mandatory. Get her last cards visit, echo, and stress if available. Next tell the orthopod he is most likely going to have very poor visualization because she is on plavix and she is going to bleed like stink and that you will not be able to do anything with her bp.

 

[sevoflurane]

Inform and document. Do the case. No block (reasonable to disagree on this one). Favorite betabolcker based hemodynamically stable regimen. Special attention to ekg placement. Routine monitors.

👍

Yep. That's was my plan exactly. We'll talk about ISB a little later....

For now, things get complicated.

Nurse comes out of the room and says she can't get an IV and that her hands are all purple and yellow from previous lab work.

I walk in and ask her if she "left her veins at home" like I usually do before I place an IV.

Then she proceeds to tell me that her last 4 surgeries required a central line placement to get IV access. 😱😱

What now....?

 

[sevoflurane]

Is she in debilitating pain?

No.. I don't think so... but cards, ortho and the patient are on the same page.

Next tell the orthopod he is most likely going to have very poor visualization because she is on plavix and she is going to bleed like stink and that you will not be able to do anything with her bp.

Nevermind the infectious risk that a hematoma carries.

He reassures me that it's a small infraspinatous tear and that he'll be in and out in 20 minutes.

This orthopod is as good as they get.

 

[sevoflurane]

Then she proceeds to tell me that her last 4 surgeries required a central line placement to get IV access. 😱😱

What now....?

Her non-operative hand is all taped out. Her surgical hand is as well. She has chubby legs with no veins to be seen.

 

[deleted126335]

👍

Yep. That's was my plan exactly. We'll talk about ISB a little later....

For now, things get complicated.

Nurse comes out of the room and says she can't get an IV and that her hands are all purple and yellow from previous lab work.

I walk in and ask her if she "left her veins at home" like I usually do before I place an IV.

Then she proceeds to tell me that her last 4 surgeries required a central line placement to get IV access. 😱😱

What now....?

ugh. I look for a peripheral IV. Since she is going to be an outpatient ( I hope) I'll even take a foot. If no luck I'll do a quick u/s scan decide on contralateral IJ or femoral.

 

[cincincyreds]

👍

Yep. That's was my plan exactly. We'll talk about ISB a little later....

For now, things get complicated.

Nurse comes out of the room and says she can't get an IV and that her hands are all purple and yellow from previous lab work.

I walk in and ask her if she "left her veins at home" like I usually do before I place an IV.

Then she proceeds to tell me that her last 4 surgeries required a central line placement to get IV access. 😱😱

What now....?

Wow, now you need to put a central line in on this beached whale on plavix who just got her DES because she is a fat pig who sits on her rear end all day watching Jerry Springer on her disability and medicaid and welfare checks with an orthopod who only cares about the next payment on his ferrari. I think I summed that up correctly. I thought anesthesia is just propofol and a tube.

My first question is whether her cardiologist is aware she is having this high risk procedure, because if the cardiologist is not aware I would just cancel this case. Taking a patient off of their plavix within 1 year of DES is a pretty risky proposition from the last paper I reviewed on this topic.

You think it is gonna be easy to put a central line in this patient, and what if you hit the carotid. Now the neck gets really big and there is now airway compromise without an IV. Unfortunately I was dumb and I don't have tail insurance so I couldn't even afford to do this case if disaster happens, I would just defer it to one of my partners and call it a day.

 

[Southpaw]

I engage in the plavix conversation with orthopod while nurses track down cards consult (I’m a little annoyed it wasn’t in her chart to begin with).

Orthopod starts quoting european studies about total joints being done with coumadin on board with no post-op complications.

I ask him how invasive this repair is going to be... he says "I’ll be in and out in about 20 minutes. Small tear... nothing major".

Cards consult arrives and confirms LAD placement of stent and no symptoms. Cards says “she’s cleared for surgery”

Did she also take her ASA today?

The ortho knows the patient better than I, and if she's willing to risk getting transfused and likely admitted to the hospital overnight because of intraoperative bleeding, then I'd do the surgery. Her pain will only get worse, and her anticoagulation strategy isn't going anywhere anytime soon.

I'd call Cardiology and ask what they mean by 'cleared for surgery'. I'd inform him/her of the information that I want/need, and that's all I ever want when a patient is seen pre-operatively. If they want to continue with the 'cleared for surgery' nonsense, then they can come in and provide the anesthetic.

I'd also be fairly annoyed that the Ortho Surgeon didn't discuss this case with me in advance.

 

[BLADEMDA]

Wow, now you need to put a central line in on this beached whale on plavix who just got her DES because she is a fat pig who sits on her rear end all day watching Jerry Springer on her disability and medicaid and welfare checks with an orthopod who only cares about the next payment on his ferrari. I think I summed that up correctly. I thought anesthesia is just propofol and a tube.

My first question is whether her cardiologist is aware she is having this high risk procedure, because if the cardiologist is not aware I would just cancel this case. Taking a patient off of their plavix within 1 year of DES is a pretty risky proposition from the last paper I reviewed on this topic.

You think it is gonna be easy to put a central line in this patient, and what if you hit the carotid. Now the neck gets really big and there is now airway compromise without an IV. Unfortunately I was dumb and I don't have tail insurance so I couldn't even afford to do this case if disaster happens, I would just defer it to one of my partners and call it a day.

Awesome post!!👍

 

[Southpaw]

Her non-operative hand is all taped out. Her surgical hand is as well. She has chubby legs with no veins to be seen.

If you see nothing above, then go for the foot. If nothing there, then US guided central line. This case is already delayed over an hour because of the discussion beforehand about her DES and now the likely need for a central line.

 

[soorg]

Ouch. What a position to be in!

Quote the ACC guidelines to everyone with ears. No elective surgery within one year of DES.

Now, as has been brought up already, what to do if she's in debilitating shoulder pain? Is the pain debilitating because she can't use her shoulder to cook/eat?

Bottom line, in my book: the heart is more important than a shoulder! Cancel, come back after 6 months. I don't care what kind of "rokstar" this ortho load is. If anything happens, bone boy MD will be the first to point fingers at you. What are you going to do when mama whale has ST elevations in the OR/PACU? It's great that her shoulder got fixed, but the myocardium is very unforgiving to ischemia/infarction. Once it's gone, it never comes back.

 

[BLADEMDA]

Ouch. What a position to be in!

Quote the ACC guidelines to everyone with ears. No elective surgery within one year of DES.

Now, as has been brought up already, what to do if she's in debilitating shoulder pain? Is the pain debilitating because she can't use her shoulder to cook/eat?

Bottom line, in my book: the heart is more important than a shoulder! Cancel, come back after 6 months. I don't care what kind of "rokstar" this ortho load is. If anything happens, bone boy MD will be the first to point fingers at you. What are you going to do when mama whale has ST elevations in the OR/PACU? It's great that her shoulder got fixed, but the myocardium is very unforgiving to ischemia/infarction. Once it's gone, it never comes back.

Following stent placement, elective surgery should be delayed until the recommended course of dual antiplatelet therapy is completed. If surgery cannot be delayed, it should be performed while the patient is on dual antiplatelet therapy. If that is not feasible, the thienopyridine should be stopped for the shortest time possible and then restarted.

http://www.aafp.org/afp/2009/1201/p1245.html

The minimum recommended duration of dual antiplatelet therapy after stent placement is one month for bare-metal stents, three months for the sirolimus (Rapamune)-eluting stent (Cypher), and six months for other drug-eluting stents. In special circumstances, two weeks of therapy after bare-metal stent placement may be considered.

 

[BLADEMDA]

Ouch. What a position to be in!

Quote the ACC guidelines to everyone with ears. No elective surgery within one year of DES.

Now, as has been brought up already, what to do if she's in debilitating shoulder pain? Is the pain debilitating because she can't use her shoulder to cook/eat?

Bottom line, in my book: the heart is more important than a shoulder! Cancel, come back after 6 months. I don't care what kind of "rokstar" this ortho load is. If anything happens, bone boy MD will be the first to point fingers at you. What are you going to do when mama whale has ST elevations in the OR/PACU? It's great that her shoulder got fixed, but the myocardium is very unforgiving to ischemia/infarction. Once it's gone, it never comes back.

I've been in this situation (similar). The patient's cardiologist agreed to stop the Plavix or effient or a week. Patient was left on aspirin. Cardiologist wrote a note in the chart saying "stable 6 months after stent placement and okay to proceed with surgery."
So, the patient got an ISB by yours truly and her rotator cuff surgery went fine.

 

[BLADEMDA]

Ouch. What a position to be in!

Quote the ACC guidelines to everyone with ears. No elective surgery within one year of DES.

Now, as has been brought up already, what to do if she's in debilitating shoulder pain? Is the pain debilitating because she can't use her shoulder to cook/eat?

Bottom line, in my book: the heart is more important than a shoulder! Cancel, come back after 6 months. I don't care what kind of "rokstar" this ortho load is. If anything happens, bone boy MD will be the first to point fingers at you. What are you going to do when mama whale has ST elevations in the OR/PACU? It's great that her shoulder got fixed, but the myocardium is very unforgiving to ischemia/infarction. Once it's gone, it never comes back.

You are correct. The majority of evidence favors waiting 1 year for elective surgery after DES placement.


Rabbitts et al.3 used a similar approach to evaluate the frequency of MACEs in 520 patients who underwent noncardiac surgery within 2 yr of DES placement. MACEs occurred in 6.4, 5.7, and 5.9% of patients when surgery was performed 0-90, 91-180, or 181-365 days after DES placement. The rate of MACEs was 3.3% when surgery was performed 365-730 days after DES placement. This apparent lower rate, though, was not significantly different than the MACE rates when surgery was performed less than 365 days after stent placement even when statistical adjustments were made to attempt to control for potential confounding variables. Neither study found that the risk of surgical bleeding was significantly associated with perioperative administration of antiplatelet therapy.


MACE= Major adverse cardiac event

 

[Southpaw]

I've been in this situation (similar). The patient's cardiologist agreed to stop the Plavix or effient or a week. Patient was left on aspirin. Cardiologist wrote a note in the chart saying "stable 6 months after stent placement and okay to proceed with surgery."
So, the patient got an ISB by yours truly and her rotator cuff surgery went fine.

I'm not the expert on this, but does a note from cardiology relieve us of responsibility and potentially a poor outcome? I sure hope not. I personally don't like depending on others to do my job for me. I don't care that cardiology thinks it's okay to proceed with surgery, it's not their job to make that call. I simply want to know the disease process and how it's currently manifesting itself. Nothing more, nothing less.

 

[BLADEMDA]

Am J Cardiol. 2009 Nov 1;104(9):1229-34.
Timing of noncardiac surgery after coronary artery stenting with bare metal or drug-eluting stents.

van Kuijk JP, Flu WJ, Schouten O, Hoeks SE, Schenkeveld L, de Jaegere PP, Bax JJ, van Domburg RT, Serruys PW, Poldermans D.
Source

Department of Vascular Surgery, Erasmus Medical Center, Rotterdam, The Netherlands.

Abstract

The current guidelines have recommended postponing noncardiac surgery (NCS) for > or =6 weeks after bare metal stent (BMS) placement and for > or =1 year after drug-eluting stent (DES) placement. However, much debate has ensued about these intervals. The aim of the present study was to assess the influence of different intervals between stenting and NCS and the use of dual antiplatelet therapy on the occurrence of perioperative major adverse cardiac events (MACEs). We identified 550 patients (376 with a DES and 174 with a BMS) by cross-matching the Erasmus Medical Center percutaneous coronary intervention (PCI) database with the NCS database. The following intervals between PCI-BMS (<30 days, <3 months, and >3 months) or PCI-DES (<30 days, <3 months, 3 to 6 months, 6 to 12 months, and >12 months) and NCS were studied. MACEs included death, myocardial infarction, and repeated revascularization. In the PCI-BMS group, the rate of MACEs during the intervals of <30 days, 30 days to 3 months, and >3 months was 50%, 14%, and 4%, respectively (overall p <0.001). In the PCI-DES group, the rate of MACE changed significantly with the interval after PCI (35%, 13%, 15%, 6%, and 9% for patients undergoing NCS <30 days, 30 days to 3 months, 3 to 6 months, 6 to 12 months, and >12 months, respectively, overall p <0.001). Of the patients who experienced a MACE, 45% and 55% were receiving single and dual antiplatelet therapy at NCS, respectively (p = 0.92). The risk of severe bleeding in patients with single and dual therapy at NCS was 4% and 21%, respectively (p <0.001). In conclusion, we found an inverse relation between the interval from PCI to NCS and perioperative MACEs. Continuation of dual antiplatelet therapy until NCS did not provide complete protection against MACEs.

 

[deleted126335]

You are correct. The majority of evidence favors waiting 1 year for elective surgery after DES placement.


Rabbitts et al.3 used a similar approach to evaluate the frequency of MACEs in 520 patients who underwent noncardiac surgery within 2 yr of DES placement. MACEs occurred in 6.4, 5.7, and 5.9% of patients when surgery was performed 0-90, 91-180, or 181-365 days after DES placement. The rate of MACEs was 3.3% when surgery was performed 365-730 days after DES placement. This apparent lower rate, though, was not significantly different than the MACE rates when surgery was performed less than 365 days after stent placement even when statistical adjustments were made to attempt to control for potential confounding variables. Neither study found that the risk of surgical bleeding was significantly associated with perioperative administration of antiplatelet therapy.


MACE= Major adverse cardiac event

The key word is elective. The argument is that the patient's severe pain elevates this case to not completely elective status. As an anesthesiologist who is just meeting the patient for the first time, I'm a little gun shy about telling her that well your ortho and cards doc agree, I do not. Live with shoulder pain for 6 more months.

 

[BLADEMDA]

I'm not the expert on this, but does a note from cardiology relieve us of responsibility and potentially a poor outcome? I sure hope not. I personally don't like depending on others to do my job for me. I don't care that cardiology thinks it's okay to proceed with surgery, it's not their job to make that call. I simply want to know the disease process and how it's currently manifesting itself. Nothing more, nothing less.

You are incorrect. The Cardiology Literature, like ours, has many studies loking at this topic. 6 months is reasonable for the right patient wanting surgery after DES. The cardiologist wrote the note and when I checked the actual data on real "risk" it was similar to 1 year; if there is a small increased risk the cardiologist bears the brunt of that decision along with patient.

I'd proceed EVERY SINGLE time with a note from a Cardiologist at 6 months or longer with a DES.

 

[BLADEMDA]

The key word is elective. The argument is that the patient's severe pain elevates this case to not completely elective status. As an anesthesiologist who is just meeting the patient for the first time, I'm a little gun shy about telling her that well your ortho and cards doc agree, I do not. Live with shoulder pain for 6 more months.

No. Not 6 more months. I'd reschedule in 5-7 days after the patient is off Plavix/Effient. I'd leave her on aspirin and get a note from Cardiology. The ISB should reduce the "stress" of this operation significantly.

IMHO, the ISB would be quite helpful to this patient.

 

[deleted126335]

I like that plan. What if cardiology comes back with "keep her on the Plavix, deal with bleeding as it comes" Would you still do the case? Would you still do the block?

 

[Agast]

This is at an outpatient center? If she honestly needs a central line for access I would cancel and re-book her on the inpatient side so if the poop hits the fan you don't have to wait for an ambulance ride to get adequate help and blood products.

 

[BLADEMDA]

I like that plan. What if cardiology comes back with "keep her on the Plavix, deal with bleeding as it comes" Would you still do the case? Would you still do the block?

Yes. I'd write a note "discussed risk/benefit with ortho and patient" Proceed with block and do the case.

 

[BLADEMDA]

http://www.anesthesia-analgesia.org/content/107/2/570.full.pdf+html



browser, select File -> Save As to save it.)
Click on image to view larger version.
Figure 4. Proposed algorithm for perioperative management of patients with bare-metal stents based on current literature. *The 2007 ACC/AHA perioperative guidelines state, "it appears reasonable to delay elective noncardiac surgery for 4&#8211;6 wk to allow for at least partial endothelialization of the stent, but not for more than 12 wk, when restenosis may occur."

 

[pd4emergence]

No.. I don't think so... but cards, ortho and the patient are on the same page.



Nevermind the infectious risk that a hematoma carries.

He reassures me that it's a small infraspinatous tear and that he'll be in and out in 20 minutes.

This orthopod is as good as they get.

My concern about the bleeding is more the ortho guynot being able to see anything through the scope. I was assuming a scope was in the plans. Sorry I didn't see the cleared from cards post. I agree with blade, if cards says they are ok with it, I'd go ahead after a serious discussion with the patient and the cardiologist and documenting both. I don't think I would relegate this lady to 6 more months of dealing with a rct if her cardiologist agrees to proceed. As for the anticoagulation issue, if the ortho pod was willing, I would much rather her continue her plavix. I also agree she would do much better with a block. Anecdotally, I find the ortho guys complain a lot less about bleeding and scope visualization when I block my shoulders. Any body else have this experience?

 

[BLADEMDA]

browser, select File -> Save As to save it.)
Click on image to view larger version.
Figure 5. Proposed algorithm for perioperative management of patients with drug-eluting stents based on current literature.

 

[BLADEMDA]

My concern about the bleeding is more the ortho guynot being able to see anything through the scope. I was assuming a scope was in the plans. Sorry I didn't see the cleared from cards post. I agree with blade, if cards says they are ok with it, I'd go ahead after a serious discussion with the patient and the cardiologist and documenting both. I don't think I would relegate this lady to 6 more months of dealing with a rct if her cardiologist agrees to proceed. As for the anticoagulation issue, if the ortho pod was willing, I would much rather her continue her plavix. I also agree she would do much better with a block. Anecdotally, I find the ortho guys complain a lot less about bleeding and scope visualization when I block my shoulders. Any body else have this experience?

The issue of Plavix should be presented to the Cardiologist. He placed the stent and knows the patient. Plavix may increase the risk of bleeding so if anything goes wrong I want it documented that Cardiology said "patient needs to be maintained on Plavix and Aspirin despite the surgery."

The last thing I need is for the Cardiologist to claim he would have stopped the Plavix for 5 days if I had asked him.

Finally, I agree that if it was me I'd rather take my chances on Plavix and ASA at 6 months with the surgery and ISB. I would not want to stop either meds. However, I would find a way to wait at least a year (if it was me having the procedure).

 

[deleted126335]

Yes. I'd write a note "discussed risk/benefit with ortho and patient" Proceed with block and do the case.

👍 I am more medicolegally gun shy than most. No block. I think both are reasonable.

 

[Southpaw]

You are incorrect. The Cardiology Literature, like ours, has many studies loking at this topic. 6 months is reasonable for the right patient wanting surgery after DES. The cardiologist wrote the note and when I checked the actual data on real "risk" it was similar to 1 year; if there is a small increased risk the cardiologist bears the brunt of that decision along with patient.

I'd proceed EVERY SINGLE time with a note from a Cardiologist at 6 months or longer with a DES.

What am I incorrect about? If a patient has an in-stent thrombosis intra-operatively are you absolved of responsibility because of a cardiology note? No. That's my point.

 

[ssmallz]

First of all, why is this pt being done in an outpt surgery center? big lady s/p DES in the LAD in less than 1 year, she's an ASA 3 or 4 in my book depending on other conditions and she should be handled in the hospital.

Secondly, the risk of thrombotic events from the stress of surgery itself is significant, even in pts w/out DESs so I would do everything we can to avoid doing this case less than 1 year s/p stent

3rd, if the cardiologist does return a note saying stay on plavix deal w/bleeding, I would ask him to specifically comment on regional anesthesia and explain to him the hemodynamic benefits that a regional technique could instill on this pt.

This case seems like it has too many red flags for me to want to proceed (no IV access, pos central line, <1 year s/p DES, MO pt, on plavix) without clear documentation that this is indeed a surgery that cannot wait b/c the risk of waiting 6 months would cause this lady greater harm than doing the surgery today. If I were to proceed, I'd want documentation form the ortho doc that by not fixing this today she will develop some debilitating injury and will ruin the rest of her life. I'd also like a cards note saying that this pt is optimized as best she can be and that the risks of periop cards events justify proceeding right now and not waiting 6 months.

When the $hit hits the fan, and you know it will, I don't want to be the one w/my neck on the chopping block while ortho dude and cards guy play dumb and say "the anesthesiologist thought it was safe to proceed, who am I to question him"

 

[urge]

This was my first case last Friday.

67 y/o obese female presents to the outpatient side for rotator cuff repair. Pmhx: DM, Obesity, Smoker. I go into bay #5 and do my focused H&P. I discover she had a DES placed 6 mo. ago. I ask her if her orthopod knows this. She says yes. Hgb 12 and platelets are 242.

How do you proceed and what info do you want?

I don't see the issue. She is on dual antiplatelet, orthopod is ok with it, so am I.

I wouldn't transfuse her any platelets no matter how much she bleeds. Orthopod will have to bovie or ligate whatever.

Block if you are comfortable, otherwise LMA.

The central line is really bothering me. Maybe stick a femoral and take it out at the end.

My first question is whether her cardiologist is aware she is having this high risk procedure, because if the cardiologist is not aware I would just cancel this case.

Is a shoulder high risk?

 

[sevoflurane]

You are incorrect. The Cardiology Literature, like ours, has many studies loking at this topic. 6 months is reasonable for the right patient wanting surgery after DES.

This is correct. I have had many conversations about this topic with my cardiology colleagues. In the right patient and for the right procedure... taking someone off plavix for 5 days once they are 6 months out of DES placement is acceptable. Factors to consider include:

-Ongoing sypmtoms (stable and unstable angina)
-Location of stent (left main vs smaller distal branch)
-Initial presentation

 

[sevoflurane]

The central line is really bothering me. Maybe stick a femoral and take it out at the end.

This was my main issue.

Big, chubby, fat neck, panus = iffy central line. Femoral or IJ/EJ

 

[urge]

What am I incorrect about? If a patient has an in-stent thrombosis intra-operatively are you absolved of responsibility because of a cardiology note? No. That's my point.

You just share the responsibility, i.e. both get screwed. Cardiology notes, writing "discussed risk, benefits, alternative", and all that nonsense people focus on don't mean anything. What matters is the outcome. And, in case of a bad outcome, did you follow standard of care?

I'm sure the plaintiff will have no problem finding anyone to testify you did not follow standard of care by stopping the plavix.

 

[sevoflurane]

First of all, why is this pt being done in an outpt surgery center? big lady s/p DES in the LAD in less than 1 year, she's an ASA 3 or 4 in my book depending on other conditions and she should be handled in the hospital.

Our ASC is literally 6 inches from the main OR of the hospital

 

[sevoflurane]

Who here does vein stripping cases?

 

[urge]

3rd, if the cardiologist does return a note saying stay on plavix deal w/bleeding, I would ask him to specifically comment on regional anesthesia and explain to him the hemodynamic benefits that a regional technique could instill on this pt.

I thought you were the expert on that.

 

[ssmallz]

I thought you were the expert on that.

I am the expert but it certainly can't hurt to have in the cards note something about risks of bleeding vs benefits of regional anesthesia. If he states something along the lines of the benefits of RA (stable hemodynamics) outweigh the risks (hematoma, bleeding), then it makes our case for choosing RA stronger if we had to defend it to some lawyer at a later time. This is especially important IMO b/c our ASRA guidlines state we should wait 7 days before placing a block and if we are disagreeing with the published literature we should have a very strong case for doing so. IMO another opinion on this will only strengthen our case

 

[urge]

I am the expert but it certainly can't hurt to have in the cards note something about risks of bleeding vs benefits of regional anesthesia. If he states something along the lines of the benefits of RA (stable hemodynamics) outweigh the risks (hematoma, bleeding), then it makes our case for choosing RA stronger if we had to defend it to some lawyer at a later time. This is especially important IMO b/c our ASRA guidlines state we should wait 7 days before placing a block and if we are disagreeing with the published literature we should have a very strong case for doing so. IMO another opinion on this will only strengthen our case

Is that what ASRA says for peripheral blocks?

 

[drccw]

My favorite notes from cardiology are the ones that say something like:

"pt cleared only for spinal anesthesia or regional anesthesia"

9 out of 10 those aren't the appropriate anesthetic technique...

The purpose of a cardiology visit isn't clearance...

Rather, it's risk stratification and optimization...

This lady is a wreck... will she ever get much better? who knows....

I think that with the increasing duration of treatment of plavix for drug eluting stents, we will be seeing the question more and more often...

I had a lady last year for a total knee replacement. She had a gazillion stents, had had episodes of restenosis in the past. 18 months since her last stent..Her cardiologist did not recommend stopping the plavix at all... so we didn't...

This lady? six months out from her stent... heart's probably as good as it's going to get... this is a low risk procedure in a high risk patient.. that's what you tell the patient, that's what you tell the orthopod.. US guided supraclavicular NB (hopefully to avoid knocking out the phrenic) and LMA...

drccw

 

[sevoflurane]

US guided supraclavicular NB (hopefully to avoid knocking out the phrenic) and LMA...

drccw

Need an IV for a ISB/SCB and LMA.... 🙄

 

[pgg]

This was my main issue.

Big, chubby, fat neck, panus = iffy central line. Femoral or IJ/EJ

Did you look for a PIV with ultrasound?

 

[drccw]

Need an IV for a ISB/SCB and LMA.... 🙄

oops forgot about that.. I'ld hit the femoral... that's easy

drccw