DrN2O

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60 yo man PMH obesity, IDDM, AFIB, HTN, OSA on CPAP, smoker, h/o RLE fem-pop, now with LEFT foot ulcer. Q wave on inferior leads. Mild cardiomegaly and pulmonary edema on CXR. "Doc, the last time I tried to walk, it nearly killed me." Overnight special from OSH, vascular add-on for foot I&D and aortogram. For the residents, what would you do? Anybody want/need a stress test?
 

Planktonmd

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60 yo man PMH obesity, IDDM, AFIB, HTN, OSA on CPAP, smoker, h/o RLE fem-pop, now with LEFT foot ulcer. Q wave on inferior leads. Mild cardiomegaly and pulmonary edema on CXR. "Doc, the last time I tried to walk, it nearly killed me." Overnight special from OSH, vascular add-on for foot I&D and aortogram. For the residents, what would you do? Anybody want/need a stress test?
No stress test needed because he will likely fail it!
Do a Sciatic + femoral nerve block and move on!
 

aneftp

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No stress test needed because he will likely fail it!
Do a Sciatic + femoral nerve block and move on!
We all know these patients are never straight forward. Say patient has INR 1.7. Would you still do it the nerve block? Surgeons especially for I and D cases usually don't have an issue with an INR of 1.7 and wanting to proceed with the case

Remember what the "guidelines/recommendation say?" To me if you are gonna to try a peripheral nerve block....always assume you will need general as a back up no matter what.

http://www.nysora.com/regional-anesthesia/foundations-of-ra/3300-ra-in-anticoagulated-patient.html

"The most recent ASRA guidelines recommended that the same guidelines on neuraxial injections apply to deep plexus or peripheral nerve blocks. Some clinicians may find this to be too restrictive and apply the same guidelines only to deep plexus and noncompressible blocks (e.g., lumbar plexus block, deep cervical plexus blocks) or to blocks near vascular areas, such as celiac plexus blocks or superior hypogastric plexus blocks. If peripheral nerve blocks are performed in the presence of anticoagulants, the anesthesiologist must discuss the risks and benefits of the block with the patient and the surgeon, and follow the patient very closely after the block."
 

kidthor

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Hopefully in this scenario I'm working for Outside Hospital and the patient's transferred. But... I suppose ankle block with verbal anesthesia adjunct.
 

AdmiralChz

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I think many of my colleagues would be comfortable with a regional technique, femoral and sciatic (or even popliteal/saphenous) are in compressible areas so anticoagulation status is less of a concern
 

Arch Guillotti

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We all know these patients are never straight forward. Say patient has INR 1.7. Would you still do it the nerve block? Surgeons especially for I and D cases usually don't have an issue with an INR of 1.7 and wanting to proceed with the case

Remember what the "guidelines/recommendation say?" To me if you are gonna to try a peripheral nerve block....always assume you will need general as a back up no matter what.

http://www.nysora.com/regional-anesthesia/foundations-of-ra/3300-ra-in-anticoagulated-patient.html

"The most recent ASRA guidelines recommended that the same guidelines on neuraxial injections apply to deep plexus or peripheral nerve blocks. Some clinicians may find this to be too restrictive and apply the same guidelines only to deep plexus and noncompressible blocks (e.g., lumbar plexus block, deep cervical plexus blocks) or to blocks near vascular areas, such as celiac plexus blocks or superior hypogastric plexus blocks. If peripheral nerve blocks are performed in the presence of anticoagulants, the anesthesiologist must discuss the risks and benefits of the block with the patient and the surgeon, and follow the patient very closely after the block."
I wouldn't think twice about it with an INR of 1.7.

I find the new guidelines you mentioned way too restrictive.
 

SaltyDog

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Sprinkle some Lasix on this guy and let the surgeon do an ankle block.

There's no anesthesia like no anesthesia.
 

BLADEMDA

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60 yo man PMH obesity, IDDM, AFIB, HTN, OSA on CPAP, smoker, h/o RLE fem-pop, now with LEFT foot ulcer. Q wave on inferior leads. Mild cardiomegaly and pulmonary edema on CXR. "Doc, the last time I tried to walk, it nearly killed me." Overnight special from OSH, vascular add-on for foot I&D and aortogram. For the residents, what would you do? Anybody want/need a stress test?
No stress test.

Lasix IV

Adductor Canal/Saphenous nerve block plus Popliteal block. Low dose Ketamine (20-3o mg IV) combined with low dose Midazolam or low dose propofol. Precedex IV may also be a good choice if the patient is hypertensive preop.

I've performed hundreds of nerve blocks under U/S with INRs above 2.0 or on patients taking medications such as Plavix, Eliquis, Xarelto, etc with zero complications.
 

BLADEMDA

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What are the recommendations of the current guidelines?: Despite sparse evidence, several national and international guidelines comment on the management of anticoagulated patients receiving PNB. The American Society of Regional Anesthesia recommendations state that for deep plexus blocks, the recommendations regarding neuraxial techniques should be applied.2 In contrast, the guideline on regional anesthesia and antithrombotic agents by the European Society of Anaesthesiology mentions that existing guidelines for neuraxial blockade do not routinely include explicit recommendations on management of PNB in anticoagulated patients.3 Likewise, the Association of Anaesthetists of Great Britain & Ireland published a guideline on regional anesthesia and patients with disturbed coagulation in which bleeding risk is described as a continuum. Accordingly, it is graded from normal (local infiltration) and hence sequentially increasing risk (superficial blocks – fascial blocks – perivascular blocks – deep blocks) up to the regional anesthesia techniques with the highest risk for bleeding (neuraxial, paravertebral).9 This guideline advises (after balancing the risk of PNB against general anesthesia) to perform PNB in patients with abnormal coagulation with ultrasound guidance by an experienced anesthesiologist. The guidelines of the German Society of Anesthesiology and Intensive Care state that except lumbar plexus blocks, therapy with platelet aggregation inhibitors or thromboprophylaxis are not absolutely contraindicated for PNB but block performance by an experienced anesthesiologist is preferred. Further, it is advised that only those blocks should be performed for which, in case of vascular puncture, local compression is feasible.10 The Guidelines of the Dutch Society of Anesthesiologists recommend the use of ultrasound to identify vascular structures. Furthermore, it divides PNB into three categories following the severity of possible bleeding complications (limited - intermediate - severe). According to this classification, depending on type and dose of the anticoagulants in blocks with intermediate or severe risk, it is advised to continue anticoagulation (limited risk) or to discontinue anticoagulant medication.7

http://journals.lww.com/rapm/Documents/ESRA 2015 Supp.pdf
 

dannyboy1

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why are we overthinking this. this is a foot ulcer in a diabetic. ankle block by podiatry (if even needed) and a little versed/fentanyl from us. Don,t know why people are suggesting stress test; this is the definition of low risk/minimally invasive surgery where you proceed to the OR regardless of exercise capacity. (unless you are thinking that the patient is having an active MI or CHF exacerbation in which you would cancel to stabilize the patient)
 
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What about the aortogram that they want to do? What if it may turn into a fem-pop?
 

BLADEMDA

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What about the aortogram that they want to do? What if it may turn into a fem-pop?
I would request that the foot I and D be done then the patient given some time to recover from his Pulmonary Edema before the Fem-Pop. A TTE would be nice along with PFTS, ABG prior to the Fem-Pop.

I'd prefer a SAB for the Fem-pop if the Coags, Platelets are acceptable and there are no contraindications like Plavix on board.
 
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SaltyDog

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I like to cover the saphenous distribution so any combination would work: Sciatic at any level and either femoral or saphenous.
I'll only add a saphenous distribution block if the surgery will spill over into that area. Plus, it's so easy for the surgeon to do a distal saphenous block or toss in some local if if they end up there when they didn't originally plan on it.
 
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DrN2O

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The surgeon backed down, did the I&D with an ankle block, and postponed the angiogram for cardiac workup. Stress test came back positive as expected, but cardiology said nothing to do. Ended up doing the angiogram and bypass a few days later with an epidural. I wonder if I should have just bit the bullet and proceed by assuming the worst.
 

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Hindsight is always 20/20. We could always assume the worst and do every case as if it were an ASA 5. However, that's not the right way. The right way is to figure out what can be optimized and fix it.

I hope the stress test was dobutamine echo, and not just an EKG. The purpose of it being to rule out left main disease or severe multi-vessel disease that would require CABG, which sounded probable in this patient. Once the latter is out of the question, all you can do is optimize the CHF and the other co-existing diseases. The surgeon and/or some bean counter might not get it, but you did the right thing.
 
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