Rotator cuff repair that is a bit unusual.

[BobBarker]

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Members do not see this ad.

I would scan the "PICC" line veins and hit it with a long 18. Hell, if no long 18g was available I would open a central line kit and use the wire to assist in sliding the included angiocath in and sew that bastard in or even use a femoral art line kit. It would have a more reasonably sized dilator. Access obtained.

 

[BLADEMDA]

 

[BLADEMDA]

I would scan the "PICC" line veins and hit it with a long 18. Hell, if no long 18g was available I would open a central line kit and use the wire to assist in sliding the included angiocath in and sew that bastard in or even use a femoral art line kit. It would have a more reasonably sized dilator. Access obtained.

In my line of work I have a saying which most of us live by:

Do what you are really good at and do it often.

Blade

 

[jetproppilot]

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

I was reading this thread along dutifully until I saw this.

Dude,

WE

are the critical care physicians.

OUR JOB is to keep our uninformed orthopods

OUTTA TROUBLE.

I am not a case cancel kinda dude, as you know.

I'd cancel this one

and the orthopedist would thank me later.

You're welcome

 

[cincincyreds]

I've got no issues with blocks under GA...none. I'm not a malpractice lawyer nor do I play one on TV.😀 If and when a patient gets a long term complication from one of your blocks under GA then you have given the attorney the angle he needs to collect money from your insurance company. You are on the DEFENSIVE here trying to justify your technique while academic geeks testify against you.

BTW, studies have shown that the Sciatic nerve is extremely resilient as well.😉

I agree. You have to think about yourself because the patients think about themselves, especially with this bad economy. I mean, if they can figure out they were asleep for a block and nerve damage occurred, they will sue you for everything you've got. Maybe they will lie about nerve damage. And you'll have that lazy piece of garbage Dr. White testifying against you in court amongst a juror of your peers.

I actually don't give sedation for blocks so patients remember them. If they don't tolerate it well, I don't do the block.

You have to practice defensive medicine and think how these clowns will try to ruin your life as that is their sole purpose.

 

[sevoflurane]

.

 

[Noyac]

I was reading this thread along dutifully until I saw this.

Dude,

WE

are the critical care physicians.

OUR JOB is to keep our uninformed orthopods

OUTTA TROUBLE.

I am not a case cancel kinda dude, as you know.

I'd cancel this one

and the orthopedist would thank me later.

You're welcome

I gotta agree with Jet here. First of all none of the orthopods I work with would have put me in this position. If they realy needed to do this case they would have sent her to us days earlier for pre-op. Secondly, I doubt any of the cards guys would have agreed to this either. Guys, this was a "high grade" LAD stent. If it goes, she goes. If we were forced to do this case it would be at the hospital, not an ASC with no invasive monitoring available should that stent go. I don't no about your ASC's but we don't have invasive monitoring capabilities at ours and we are attached to our hospital essentially. So those of you calling for a central line are forgetting something. Sevo did the only thing he could do here, an IV.

Then some of you are worried about doing a central line in someone anticoagulated but we are considering an ISB. Personally, I'm not worried about doing either one of those procedures on someone like this but you can't do both. Or can you? Here's the deal, if your worried about a hematoma from the CVP the you should theoretically worry about it from the ISB as well. Then are you doing a CVP on one side and an ISB on the other? Now, here's another thought, can't you do the ISB on the correct side then do the CVP on the same side? I don't see why not except not in this pt because you need IV access before the block can be performed. And if OU have that IV access, you don't need the CVP.

Great case Sevo.

 

[Noyac]

Plus, this is a bullsh*t case because there is no way that a fatty like this can be in so much pain from this small of a cuff tear. Just look at the size of her leg. She doesn't use her limbs for much at all. If she were using them she wouldn't be so fat. I'd make her wait. This is a very crude statement but we need to take everything into account here. We are sometimes the pts most reasonable proponent. I have had surgeons send pts to me so that I would cancel them and they don't have to be the bad guy and ultimately lose the pt for good. I don't mind being that guy as long as the terms are clear beforehand. I will cancel a case for a surgeon so that he can say that anesthesia won't do the case now and we need to wait until it is a more appropriate time for your surgery. Pts come to see surgeons, they are assigned to us. We are still responsible for their wellbeing.

 

[BLADEMDA]

I agree. You have to think about yourself because the patients think about themselves, especially with this bad economy. I mean, if they can figure out they were asleep for a block and nerve damage occurred, they will sue you for everything you've got. Maybe they will lie about nerve damage. And you'll have that lazy piece of garbage Dr. White testifying against you in court amongst a juror of your peers.

I actually don't give sedation for blocks so patients remember them. If they don't tolerate it well, I don't do the block.

You have to practice defensive medicine and think how these clowns will try to ruin your life as that is their sole purpose.

Sad but true.

 

[BLADEMDA]

Plus, this is a bullsh*t case because there is no way that a fatty like this can be in so much pain from this small of a cuff tear. Just look at the size of her leg. She doesn't use her limbs for much at all. If she were using them she wouldn't be so fat. I'd make her wait. This is a very crude statement but we need to take everything into account here. We are sometimes the pts most reasonable proponent. I have had surgeons send pts to me so that I would cancel them and they don't have to be the bad guy and ultimately lose the pt for good. I don't mind being that guy as long as the terms are clear beforehand. I will cancel a case for a surgeon so that he can say that anesthesia won't do the case now and we need to wait until it is a more appropriate time for your surgery. Pts come to see surgeons, they are assigned to us. We are still responsible for their wellbeing.

1) timing of surgery with the LAD stent is debatable. I agree Cards needs to clear her for this procedure at 6 months. Once cleared by Cards and the patient understands the small but possible increased risk I do the case.

2) Plavix and aspirin don't bother me much for a PNB. Neuraxial and Lumbar Plexus are a different story. Why would you get a hematoma using U/S? Can't see? Lack of experience? My incidence of hematoma using just a NS is less than 1%; with U/S it's zero.

3) Look for a large IJ. Avoid the carotid. Still scared? Do a Femoral line then. Why couldn't you do a Femoral line in an ASC?

Finally, cancelling the case is reasonable if you don't have Cards clearance. The block isn't required to do the case so skip it.

 

[sevoflurane]

I was reading this thread along dutifully until I saw this.

Dude,

WE

are the critical care physicians.

OUR JOB is to keep our uninformed orthopods

OUTTA TROUBLE.

I am not a case cancel kinda dude, as you know.

I'd cancel this one

and the orthopedist would thank me later.

You're welcome

Well then... allow me to retort:

[YOUTUBE]http://www.youtube.com/watch?v=FORtwA2lsjM[/YOUTUBE]

Had to pull some 'ol school... 😀

Coupla thoughts for you Jet.

Take the patient off plavix with an LAD stent? No... especially with the cards note.

Do the case? You say you wouldn't do it cuz she took her plavix that am. Is it the bleeding you are afraid of?

Cancel the case? This is your position... but not mine and here is why:

Now... you have a patient that works for a living and has no disability. The patient needs to sustain herself somehow... she needs to get back to work. She is a waitress and needs her shoulder fixed SOONER rather than later to put food on the table. This is ONE issue to consider.

She also has invested time and effort and $$$ to see her primary care physician, her cardiologist and her orthopod. All 3 providers concur in proceeding with planned surgery continuing plavix.

At this point I understand... the above may not be a good enough reason. So you pull your orthopod aside and ask him WHY he must do this case:

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"

Do you know about these European studies he is referring to?

http://www.jbjs.boneandjoint.org.uk/content/93-B/11/1497.abstract


http://www.ncbi.nlm.nih.gov/pubmed/19844768

"We have shown that a safe alternative is to continue the steady-state warfarin peri-operatively in patients on long-term anticoagulation requiring total knee replacement."


I'm not promoting this... just saying... this orthopod knows his stuff.


Now.. let's take a step back... this is NOT a total joint.

This is a 2 inch incision and 3 sutures. Too boot... I've done tons and tons of joints with this guy. I know he is LEGIT... and I believe him.

But we take it a step further.

I explain to the patient that she is at risk for bleeding that might require blood products... additionally, it may make the surgery more complex/difficult and she may be at risk for infection post-op.

She has had this conversation with 4 different doctors... SHE UNDERSTANDS ALL RISKS and WISHES TO PROCEED.

Heavy documentation in the chart IS A MUST.

Proceed to surgery. 10 cc's of blood loss.

Is this case ideal...?

Hell No. We all know this.

Can we sometimes step outside of our box and provide a needed service? Absolutely... despite it being a little uncomfortable.

Would I cancel a case if someone was on plavix for a superficial skin lesion...? No... sir... I wouldn't. But you wouldn't either...

I am not a case cancel kinda dude, as you know.

I'd cancel this one

and the orthopedist would thank me later.

You're welcome

No... he thanked me at the end of the case. 😉


Regarding LAD stent placement 6 months ago....

She is still on plavix for the entire case.

Does that stress response during a 20 minute repair increase the chance of restenosis even with plavix on board during the case and during the last 6 months....? I'm not so sure.

According to 2 of the cardiologists I spoke to this morning...

Re-thrombosis won't happen if you have no symptoms and are 6 months out and you keep them on plavix. The issue is the type of case and it's risks for bleeding.

 

[sevoflurane]

Obviously some people are on the fence on this one...

Some people would cancel the case...

Some people would do it...

These decisions are not easy ones.

 

[sevoflurane]

Finally, cancelling the case is reasonable if you don't have Cards clearance. The block isn't required to do the case so skip it.

I wouldn't do the case w/o cards clearence.

 

[Arch Guillotti]

IMHO "clearance" by cards is all relative. I have yet to have a cardiologist agree to have a patient come off plavix with a DES at <1 year. It isn't surprising that cards "cleared" the patient - as long as the stent doesn't clot off WTF do they have to worry about?

 

[sevoflurane]

IMHO "clearance" by cards is all relative. I have yet to have a cardiologist agree to have a patient come off plavix with a DES at <1 year. It isn't surprising that cards "cleared" the patient - as long as the stent doesn't clot off WTF do they have to worry about?

Pretty much what cards said this morning... they need to protect their stent, and I fully understand that... especially for a semi-elective case. "Clearing" also means no symptoms or other funk that would put her in danger.

At that point... it's a surgical issue and the surgeon's (and anesthesiologists) decision.

They are in the clear.

 

[Idiopathic]

can anyone do a literature search for me and bold some of the abstract and italicize some of that so i can determine best practice?

 

[Noyac]

1) timing of surgery with the LAD stent is debatable. I agree Cards needs to clear her for this procedure at 6 months. Once cleared by Cards and the patient understands the small but possible increased risk I do the case.

2) Plavix and aspirin don't bother me much for a PNB. Neuraxial and Lumbar Plexus are a different story. Why would you get a hematoma using U/S? Can't see? Lack of experience? My incidence of hematoma using just a NS is less than 1%; with U/S it's zero.

3) Look for a large IJ. Avoid the carotid. Still scared? Do a Femoral line then. Why couldn't you do a Femoral line in an ASC?

Finally, cancelling the case is reasonable if you don't have Cards clearance. The block isn't required to do the case so skip it.

Just to debate a bit , all respect present.
1. Literature supports waiting 1yr for DES stent. This one is in the LAD! Cards will clear anyone for surgery as long as they are on plavix😱 like someone said, they are only worried about the stent.
2. We are in agreement here. But.
I have never had a hematoma from a block. Ever! Maybe I haven't done enough 😉
3. I would look for an EJ. I wouldn't do a femoral in this case unless it was the absolute last option. Sitting position, not a fan.

 

[Noyac]

Sevo,
You changed to terms on me some. I didn't know she used that arm. The looks of her said otherwise. Anyhow, if we cancel she hasn't lost anything with regards to her doctor visits. Something tells me she may have seen a midlevel tho. Those visits still count in 6 months. We all know that there is no magic number of days when a stent becomes stable. It doesn't miraculously become stable at 366 days. So judgement is key. You obviously used your judgement here.

 

[sevoflurane]

It doesn't miraculously become stable at 366 days.

Excellent point Noy. In our conversation this a.m., cards brought this up and gave an example of a recent patient of his that was 14 mo. out from placement of a DES... They took him off plavix and subsequently his stent re-thrombosed.

Yeah... some of our waitresses over here don't look like the ones at the Diamond bell... 😉

 

[sevoflurane]

can anyone do a literature search for me and bold some of the abstract and italicize some of that so i can determine best practice?

😛

Just channeling my inner Jet.

Dang... it.

Passed 2000 posts and didn't even notice it. 😡

 

[Noyac]

Excellent point Noy. In our conversation this a.m., cards brought this up and gave an example of a recent patient of his that was 14 mo. out from placement of a DES... They took him off plavix and subsequently his stent re-thrombosed.

Yeah... some of our waitresses over here don't look like the ones at the Diamond bell... 😉

That's why this case is crazy.

I've had plenty of shoulder injuries in the past. Not the least of which was just this summer. My recommendation to this lady is PT. There are many exercises to strengthen the surrounding muscles to compensate for the rotator cuff tear which I this lady is not every big since in only took a few sutures. If this were my shoulder I wouldn't be operating on it. I think your orthopod really likes to operate. 😉

Headed to diamond bell now.

 

[sevoflurane]

Yes he does. He gets 2 rooms on tuesday and thursday. 🙄

What makes this case interesting to me is that she remained anticoagulated. I'd like to see Re-thrombosis rates in patients undergoing non-cardiac surgery who remian on plavix and asa 6 months after stent placement. As far as I know, this hasn't been looked at heavily.

It's a different beast altogether once you remove the antiplatelet agents for non-cardiac surgery at any time before 1 yr. with DES or 6 weeks with BMS.

Have fun tonight... 😎

 

[pd4emergence]

I see something similar to this every few months. Stent, on plavix, sometimes the pt has stopped it on their own, sometimes the surgeon knows, most of the time not, occasionally they have actually seen their cardiologist beforehand. Cards guys here are all over the board. I think most of them would have allowed this to proceed as long as she kept her plavix and Asa going. As for me, if there is frank discussion with both the patient and the cardiologist and the orthopod and everyone is adamant to proceed, if the patient truly understands the risk, I would find it hard not to do the case. I wouldn't feel good about it but it is what it is.

Block/cvl under u/s, sure. I do think a case could be made for an aline. But it sounds like a really short procedure, I am not sure I would put one in.

Blocks under ga...I can see myself doing a femoral, maybe a popliteal, but just don't see myself sticking a neck or a back for a block while the pt is asleep. I have seen the studies, but I have heard the horror stories and those scare me more.

The ortho guys here are very "me fix bones". They rarely know anything about their patients. This scenario happens more than I would like. It scares me to death when some one has showed up and stopped their anticoagulants without anybody knowing. I had a cataract do this a while back. Stent in for two months, stopped her plavix cause she was having surgery, cp in holding area, huge st elevations on ekg, died in the cath lab.

 

[proman]

We should have much more information in the next 2 years. There are multiple studies that are currently recruiting patients. The most interesting one is in Germany, placebo controlled trial of 12 months of Plavix vs 6 months. My thoughts are that 6 months of dual therapy is sufficient. Surgery on dual therapy is probably fine too. I also think the VerifyNow P2Y12 test should be done on these patients. ~15% of the tests I send show zero response to Plavix, many more show reduced response.

 

[fakin' the funk]

Did you look for a PIV with ultrasound?

This.

 

[fakin' the funk]

My $0.02.

Why all of a sudden do we care so much what the cardiologist says? Do we care when they say "avoid hypotension and hypoxia" or "OK to proceed with spinal" in a patient on clopidogrel?

Why do we now lean on a cardiologist's recommendations when they are clearly going against their own society's recommendations for scheduling of surgery after DES?

This is an elective case. I don't care how many tears flow. Logistic issues for this ASA3/4 patient with no IV access aside. The patient and cardiologist knew the 12-month rule when that DES went in. Six months ago, both patient and cardiologist were convinced that this was a life-threatening lesion, no? This is an elective case and the guidelines are clear. We have no reason to think that proceeding with this case is clearly the right decision, but every reason to think that if we proceed and are wrong about that that the result is catastrophic for the patient.

Sure we are doctors in love with our femoral-nerve-block-with-U/S-under-GA-on-plavix-no-hematoma technique...but we're still doctors and we still make our own decisions to manage our patients.

 

[sevoflurane]

We should have much more information in the next 2 years. There are multiple studies that are currently recruiting patients. The most interesting one is in Germany, placebo controlled trial of 12 months of Plavix vs 6 months. My thoughts are that 6 months of dual therapy is sufficient. Surgery on dual therapy is probably fine too. I also think the VerifyNow P2Y12 test should be done on these patients. ~15% of the tests I send show zero response to Plavix, many more show reduced response.

👍

For those who don't know what the P2Y12 test is:

http://www.news-medical.net/news/20...ives-CE-mark-approval-for-prognostic-use.aspx

http://www.thrombosisjournal.com/content/7/1/4

Are you ordering P2Y12 tests proman?

If so, in what context (I woulda liked to see one done pre-op on the patient mentioned above).

Thx.

 

[proman]

Are you ordering P2Y12 tests proman?

If so, in what context (I woulda liked to see one done pre-op on the patient mentioned above).

Thx.

We just recently got it. We do a decent number of hybrid CABG (robotic + percutaneous stent) so I check it after the Plavix is given. Takes about 20 minutes for the result. One patient had received 600mg load for cath 2 days prior then 75mg daily until surgery. I checked it because he was supposed to get an RCA stent have the robotic CAB. There was zero platelet inhibition and he was started on prasugrel instead.

 

[sevoflurane]

We just recently got it. We do a decent number of hybrid CABG (robotic + percutaneous stent) so I check it after the Plavix is given. Takes about 20 minutes for the result. One patient had received 600mg load for cath 2 days prior then 75mg daily until surgery. I checked it because he was supposed to get an RCA stent have the robotic CAB. There was zero platelet inhibition and he was started on prasugrel instead.

Awesome.

Plavix non-responders/low responders is a little scary. Good test.

Sounds like you are putting in coronary sinus catheters... 👍

Thanks.

 

[dhb]

Plavix non-responders/low responders is a little scary.

But very common probably 30%

The guys here don't stop aspirin and plavix or AVK and do blocks on these patients; they haven't had any problems (which doesn't mean they won't) and they do a lot of peripheral vascular cases

 

[ssmallz]

What makes this case interesting to me is that she remained anticoagulated. I'd like to see Re-thrombosis rates in patients undergoing non-cardiac surgery who remian on plavix and asa 6 months after stent placement. As far as I know, this hasn't been looked at heavily.

This IMO is the important point to consider when proceeding with surgery or not. Sure we could do this case and keep her on plavix but surgery itself leads to an increase in thromboembolic events. As far as I'm aware, there isn't enough literature out there to see if the risk of stent restenosis is similar if we keep her on plavix and do the case after 6 months or wait 1 year and hold the plavix. Until we have some evidence to back up our practice I would think long and hard before doing an elective case prior to 1 year on this type of pt.

 

[proman]

Awesome.

Plavix non-responders/low responders is a little scary. Good test.

Sounds like you are putting in coronary sinus catheters... 👍

Thanks.

We don't routinely do CS catheters for the TECABs. Surgeon uses the Edwards EndoPlege cannula to deliver cardioplegia. He's leaving in a few months so maybe the new guy will want it. The CS catheter is usually done for our mini mitrals and we don't do a whole of them.

 

[BLADEMDA]

👍

For those who don't know what the P2Y12 test is:

http://www.news-medical.net/news/20...ives-CE-mark-approval-for-prognostic-use.aspx

http://www.thrombosisjournal.com/content/7/1/4

Are you ordering P2Y12 tests proman?

If so, in what context (I woulda liked to see one done pre-op on the patient mentioned above).

Thx.

I order them. For example, ASA4 train wreck shows up for surgery. Off Plavix for 5 days. Why not just check the test and see if any plavix activity? Usually there isn't any at all. Then in PACU I can do any block needed without worry about ASRA guidelines.

But, do any of you people have the nerve to do a spinal even if the test shows no plavix activity? What if the patient is off Plavix for 5 days and all your tests come back fine (Platelet count 178,000, PFA-100 is normal, TEG normal, Verify now shows no plavix, etc.) will you do the spinal? What about 3 days off Plavix with same scenario?

 

[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.

I see many of you don't read my references. Take a close look at this study. Now, here is your test question: Based on the results of this study are patients at greater risk of rethrombosis at 6 months vs. 12 months assuming continuation of dual anti-platelet therapy?

 

[BLADEMDA]

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.

Another study in our literature; they recommend 1 year but state no statistical difference in MACE after 180 days vs. 365 days.


http://www.ncbi.nlm.nih.gov/pubmed/18813037

 

[BLADEMDA]

So if A Cardiologist says 6 months is good enough for his/her patient there is sufficient evidence in the literature to proceed with the case.

 

[BLADEMDA]

Best practice suggests that these risks should be jointly assessed by the orthopedic surgeon and cardiologist. Those patients with stents at high risk of thrombosis should have surgery delayed if possible. There is little data supporting a significantly increased bleeding risk associated with mortality in orthopedic patients when antiplatelet therapy is continued perioperatively.


http://www.ncbi.nlm.nih.gov/pubmed/21886534

 

[proman]

I order them. For example, ASA4 train wreck shows up for surgery. Off Plavix for 5 days. Why not just check the test and see if any plavix activity? Usually there isn't any at all. Then in PACU I can do any block needed without worry about ASRA guidelines.

But, do any of you people have the nerve to do a spinal even if the test shows no plavix activity? What if the patient is off Plavix for 5 days and all your tests come back fine (Platelet count 178,000, PFA-100 is normal, TEG normal, Verify now shows no plavix, etc.) will you do the spinal? What about 3 days off Plavix with same scenario?

Blade I can tell you that no one knows what the P2Y12 shows after discontinuing Plavix. If you're interested you (we?) should look all the patients you've tested and how many days they've been off. It would be an easy publication and contribute to what we know about Plavix.

 

[proman]

Today I did a fem-pop in a 50 something year old female s/p CABG and brittle DM. Prior to her CABG a year ago she had an MI and VF arrest. She had been taking ASA/Plavix since the CABG and the vascular surgeon told her to continue it. I checked a P2Y12 here are the results:

P2Y12 Reaction Units: 362
Base PRU: 348
% Platelet Inhibition: <1%

It took less than 20 minutes to get the results (it's really a 5 min test). If she actually had an indication for dual antiplatelet therapy like a DES she would have been completely unprotected.

 

[jetproppilot]

Well then... allow me to retort:

[YOUTUBE]http://www.youtube.com/watch?v=FORtwA2lsjM[/YOUTUBE]

Had to pull some 'ol school... 😀

Coupla thoughts for you Jet.

Take the patient off plavix with an LAD stent? No... especially with the cards note.

Do the case? You say you wouldn't do it cuz she took her plavix that am. Is it the bleeding you are afraid of?

Cancel the case? This is your position... but not mine and here is why:

Now... you have a patient that works for a living and has no disability. The patient needs to sustain herself somehow... she needs to get back to work. She is a waitress and needs her shoulder fixed SOONER rather than later to put food on the table. This is ONE issue to consider.

She also has invested time and effort and $$$ to see her primary care physician, her cardiologist and her orthopod. All 3 providers concur in proceeding with planned surgery continuing plavix.

At this point I understand... the above may not be a good enough reason. So you pull your orthopod aside and ask him WHY he must do this case:




Do you know about these European studies he is referring to?

http://www.jbjs.boneandjoint.org.uk/content/93-B/11/1497.abstract


http://www.ncbi.nlm.nih.gov/pubmed/19844768

"We have shown that a safe alternative is to continue the steady-state warfarin peri-operatively in patients on long-term anticoagulation requiring total knee replacement."


I'm not promoting this... just saying... this orthopod knows his stuff.


Now.. let's take a step back... this is NOT a total joint.

This is a 2 inch incision and 3 sutures. Too boot... I've done tons and tons of joints with this guy. I know he is LEGIT... and I believe him.

But we take it a step further.

I explain to the patient that she is at risk for bleeding that might require blood products... additionally, it may make the surgery more complex/difficult and she may be at risk for infection post-op.

She has had this conversation with 4 different doctors... SHE UNDERSTANDS ALL RISKS and WISHES TO PROCEED.

Heavy documentation in the chart IS A MUST.

Proceed to surgery. 10 cc's of blood loss.

Is this case ideal...?

Hell No. We all know this.

Can we sometimes step outside of our box and provide a needed service? Absolutely... despite it being a little uncomfortable.

Would I cancel a case if someone was on plavix for a superficial skin lesion...? No... sir... I wouldn't. But you wouldn't either...





No... he thanked me at the end of the case. 😉


Regarding LAD stent placement 6 months ago....

She is still on plavix for the entire case.

Does that stress response during a 20 minute repair increase the chance of restenosis even with plavix on board during the case and during the last 6 months....? I'm not so sure.

According to 2 of the cardiologists I spoke to this morning...

Re-thrombosis won't happen if you have no symptoms and are 6 months out and you keep them on plavix. The issue is the type of case and it's risks for bleeding.

Excellent.

I'm glad the case turned out the way it did.

Here's the problem man:

Dude, I've done some

REAL SURGERIES....LIKE....UHHhHH..

HEART

SURGERIES

EMERGENTLY

PATIENT ON

PLAVIX.

And that

ONE THING

Plavix

made an emergent CABG

DIFFICULT.

Difficult, man. Like you wanna

BREAK SOMETHING

difficult.

Sooooooooooo.....

LET'S TALK.

WE'RE TALKING ABOUT

ELECTIVE SHOULDER SURGERY.😱

Like

COMPLETELY, TOTALLY,


ELECTIVE.


Plavix is like your In Laws:

You never wanna see 'em but at the

LAST MINUTE

they show up

and they

NEVER GO AWAY.

Point being:

Cancel a Plavix-questionable case.

And avoid your In Laws

no matter what the cost.

And you will be right.

You're welcome.

 

[Robert Loblaw]

not that this discounts this study, per se, but the dr. poldermans has been fired for ethics violations wrt to his research. in my opinion, it calls into question the integrity of the entirety of his publications...

 

[fakin' the funk]

can anyone do a literature search for me and bold some of the abstract and italicize some of that so i can determine best practice?

 

[BLADEMDA]

Today I did a fem-pop in a 50 something year old female s/p CABG and brittle DM. Prior to her CABG a year ago she had an MI and VF arrest. She had been taking ASA/Plavix since the CABG and the vascular surgeon told her to continue it. I checked a P2Y12 here are the results:

P2Y12 Reaction Units: 362
Base PRU: 348
% Platelet Inhibition: <1%

It took less than 20 minutes to get the results (it's really a 5 min test). If she actually had an indication for dual antiplatelet therapy like a DES she would have been completely unprotected.

Would you do a spinal in this patient? Even though she is still on Plavix you have evidence the drug isn't doing anything to the platelets.

That's why I do the test if I want to do a block or SAB.

For those who only follow "protocol" ASRA still cautions against proceeding with Regional in this case. Another reason I prefer cognitive thought, education and literature review over just blindly following protocols.