spinal with patients taking plavix

[anesthesia11230]

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For the anesthesia "cowboys" out thier who are considered more risky than the norm, if a patient is taking low dose plavix (25mg) how long would they have had to stop it before you even consider thinking about spinal

ex. for a 96 yr old female S/P fall sustaining Left hip fx going in for ORIF
wait the recommended 7 - 10 days or sooner?

thanks
best regards

 

[anesthesia11230]

we ended up providing GA and she is currently still intubated ventilated although she only recieved about 150 ug fentanyl...she is hardly 50kg frail lady even if and when we extubate her i forsee nice pneumonia developing although she does not have any pulmonary issues...main medical history is cardiac

thanks for the consideration

http://www.02demand.com
clinical online excellence of anesthesia

 

[urge]

SPAM!!!


/thread

 

[VentdependenT]

For the anesthesia "cowboys" out thier who are considered more risky than the norm, if a patient is taking low dose plavix (25mg) how long would they have had to stop it before you even consider thinking about spinal

ex. for a 96 yr old female S/P fall sustaining Left hip fx going in for ORIF
wait the recommended 7 - 10 days or sooner?

thanks
best regards

Gotta wait a week bud.

 

[anesthesia11230]

agreed

just curious if anyone gutsy crazy enough.
Even Jet and Mil have their limits of insanity (kidding BTW)

thanks for the reply Vent

 

[Laurel123]

Little propofol and pop in an LMA. I rarely do spinals on my broken hip patients unless there is a clear advantage to general. I don't use intrathecal morphine because they are usually 90 to 100 years old and sleepy or demented baseline.

 

[deleted126335]

.

 

[powermd]

For the anesthesia "cowboys" out thier who are considered more risky than the norm, if a patient is taking low dose plavix (25mg) how long would they have had to stop it before you even consider thinking about spinal

ex. for a 96 yr old female S/P fall sustaining Left hip fx going in for ORIF
wait the recommended 7 - 10 days or sooner?

thanks
best regards

Where is the hip fracture- femur, trochanteric, or inter-trochanteric? You need to fix trochanteric fractures within 72 hours or else you get non-union problems. Femur and inter-trochanteric fractures can bleed a lot, which may be a problem if you need to transfuse acutely an elderly patient with poor cardiopulmonary function. If you wind up with pulmonary edema an LMA ain't gonna do the job.

 

[militarymd]

agreed

just curious if anyone gutsy crazy enough.
Even Jet and Mil have their limits of insanity (kidding BTW)

thanks for the reply Vent

I wouldn't do that.

 

[lobelsteve]

Had an elective procedure I cancelled on a guy this week becasue he woke up and took a Plavix 4 days prior to the procedure. He almost lied to the nurse because he remembered to hold it for the 3 days before that.

He got angry when I reschedule him, but after the explanation of spinal hematoma he cooled off a bit.

 

[anesthesia11230]

we provided ETT GA
she had an left intratrochanteric fracture
96 y . o female fx her right hip several months prior

h/o uncontrolled HTN (systolic upper 190's), CAD (no recent cardiac cath) questionable CHF mentioned in the ortho note (dont know how valid this note was) frail thin lady not even reaching 50 kg

inital medicine consult note: patient was not cleared for surgery until having a cardiac consult

told this to the ortho attending and his reply was ...dr so and so will be here shortly and he will clear her for me

induced with etomidate, sux (no Aline)
propofol with her i think would be disaster esp without slow titration using an Aline for steady control of MAP

she was solid throughout the case
my only major concern was extubating her...although she didnt have any major pulmonary issues she just didnt seem strong enough to give a nice deep breathe (vital capacity) for a strong cough...though pneumonia trach ,,,vent dependent etc....reason for my spinal inquiry...to how far can we push the limits with plavix

anyways case went well...kept her intubated/ventilated for about 1 hr after the case...now extubated doing fine ( i guess) already transfered from the unit

will check up on her about now
thanks for the replies

 

[Jeff05]

Interindividual variability in platelet inhibition was demonstrated in both patients and healthy volunteers. In patients, 7 of 32 (22%) were clopidogrel nonresponders, 10 of 32 (32%) were low responders, and 15 of 32 (47%) were responders. Circulation. 2004;109:166-171

she may be a non responder. if available, run a quick TEG and see what percent of plt are functional. then, do a nice, light spinal.

ASRA recommends 7 days for plavix.

GA is fine too, lower incidence of POCD, esp. in this lady.

 

[anesthesia11230]

Curious how you guys would take the medical clearance issue:

initial medicine consult states patient not medically cleared for surgery and recommend cardiac consult (just the night before this consult was made)

patient has uncontrolled hypertension (systolic upper 190)
hx of CAD (no recent cardiac cath): patient is a poor historian
health care proxy is the daughter who is not much help esp on the phone
patient is taking amiodarone for which no one knows why
suggested hx of heart failure (ortho note taken with grain of salt)

the ortho attending has good ties with another medical attending...and patient soon the patient is cleared

wanting to have a further work up of this patient... is it simply academic with really not much clinical worth?

afterall the patient did fine
and really i was not troubled enough to even place an A-line
so prob not a major issue but for some reason if it had gone bad...and suffered from a perioperative cardiac event

i would have looked like an idiot
any comments?
------------------------------------
http://www.02demand.com
online community of clinical excellence of anesthesia

 

[huktonfonix]

the question is what are you going to do with the knowledge from that "medical clearance"? Is there anything to optimize? If she doesnt have any of the "active cardiac conditions" mentioned in the ACC/AHA that you can optimize then its not likely that you will gain much by postponing the surgery. Are you going to take this lady to cath or CABG for her CAD before her hip surgery? It would be highly unlikely to benefit her especially given the fact that she would be bedridden and waiting at least for a couple of weeks if she had an angioplasty (more with a stent). Its all about weighing the risk vs benefit to the patient.
As far as the spinal goes, it would take some balls to blatantly go against the ASRA Consensus statement unless you could prove a very strong benefit.

 

[militarymd]

Curious how you guys would take the medical clearance issue:

initial medicine consult states patient not medically cleared for surgery and recommend cardiac consult (just the night before this consult was made)

patient has uncontrolled hypertension (systolic upper 190)
hx of CAD (no recent cardiac cath): patient is a poor historian
health care proxy is the daughter who is not much help esp on the phone
patient is taking amiodarone for which no one knows why
suggested hx of heart failure (ortho note taken with grain of salt)

the ortho attending has good ties with another medical attending...and patient soon the patient is cleared

wanting to have a further work up of this patient... is it simply academic with really not much clinical worth?

afterall the patient did fine
and really i was not troubled enough to even place an A-line
so prob not a major issue but for some reason if it had gone bad...and suffered from a perioperative cardiac event

i would have looked like an idiot
any comments?
------------------------------------
http://www.02demand.com
online community of clinical excellence of anesthesia

dude, shes' 97 years old....

No one is going to stent her, wait 6 months on plavix, then fix her hip.

You would have been in idiot to wait on a medical consult....you're a doctor.

 

[anesthesia11230]

blunt and to the point
like your style mil

 

[Laurel123]

Curious how you guys would take the medical clearance issue:

initial medicine consult states patient not medically cleared for surgery and recommend cardiac consult (just the night before this consult was made)

patient has uncontrolled hypertension (systolic upper 190)
hx of CAD (no recent cardiac cath): patient is a poor historian
health care proxy is the daughter who is not much help esp on the phone
patient is taking amiodarone for which no one knows why
suggested hx of heart failure (ortho note taken with grain of salt)

the ortho attending has good ties with another medical attending...and patient soon the patient is cleared

wanting to have a further work up of this patient... is it simply academic with really not much clinical worth?

afterall the patient did fine
and really i was not troubled enough to even place an A-line
so prob not a major issue but for some reason if it had gone bad...and suffered from a perioperative cardiac event

i would have looked like an idiot
any comments?
------------------------------------
http://www.02demand.com
online community of clinical excellence of anesthesia

I agree with the above that don't believe that official medical clearance is necessary.

CHF - listen to her heart and lungs and look at her sats. Make sure she isn't in florid pulmonary edema.

Not going to stent, CABG or replace her valves - so no further cardiac workup.

SBP in 190's - She is 97 and has a broken hip. Not surprised. And a little sedation and pain meds, and it will be better.

On Plavix, do a general. 97 year old need barely a wiff of volatile and they are anesthetized.

The thing is this is a super old woman with a broken hip. If you don't fix it and spend days waiting for plavix to wear off or getting some extensive workup or cardiology consults, she will lay immobile in bed in intense pain putting her at great risk for PE, pneumonia, MI etc.

 

[militarymd]

blunt and to the point
like your style mil

👍

 

[Planktonmd]

we provided ETT GA
she had an left intratrochanteric fracture
96 y . o female fx her right hip several months prior

h/o uncontrolled HTN (systolic upper 190's), CAD (no recent cardiac cath) questionable CHF mentioned in the ortho note (dont know how valid this note was) frail thin lady not even reaching 50 kg

inital medicine consult note: patient was not cleared for surgery until having a cardiac consult

told this to the ortho attending and his reply was ...dr so and so will be here shortly and he will clear her for me

induced with etomidate, sux (no Aline)
propofol with her i think would be disaster esp without slow titration using an Aline for steady control of MAP

she was solid throughout the case
my only major concern was extubating her...although she didnt have any major pulmonary issues she just didnt seem strong enough to give a nice deep breathe (vital capacity) for a strong cough...though pneumonia trach ,,,vent dependent etc....reason for my spinal inquiry...to how far can we push the limits with plavix

anyways case went well...kept her intubated/ventilated for about 1 hr after the case...now extubated doing fine ( i guess) already transfered from the unit

will check up on her about now
thanks for the replies

Here is what I would have done:
No pre-op medications of any kind.
Fascia iliaca block.
Induce with 50 mg propofol, 50 mg Lidocaine, 25 mcg fentanyl and a squirt of Phenylephfrine, insert LMA.
Maintain with little sevo + N2o and spontaneous ventilation.
Take LMA out, go to recovery.

 

[jetproppilot]

agreed

just curious if anyone gutsy crazy enough.
Even Jet and Mil have their limits of insanity (kidding BTW)

thanks for the reply Vent

Plavix for me means they get a snorkel. I like Plank's plan.

No needle in the back.

 

[Anesthesia1979]

97 y/o on plavix and uncontrolled HTN, ? CAD, etc....

before I put her under, I'm going to wait for that consult if there already is one consultant saying "not cleared" till seen by cardiology. go back to OR and adverse event occurs before being seen by cardiology and you may get to try and explain yourself on the stand. However, before cards writes any official notes, I want to have my input about what is said in that note.

she's getting that awake a-line before I put her under. She probably doesn't autoregulate so well and I want tight control of hemodynamics. Also the ortho guys will lose a bit of blood and think nothing of it... her EBV being dirt old/ 50kg and the fact that she may ooze with plavix makes me want to have that a-line for some frequent blood draws.

Don't like to do LA spinals on people that old anyhow.

So for her, 2iv's, a-line, if easy looking airway, maybe some lido, prop, fent, neo, while trying to maintain her baseline maps and then DL-> ett. blood and ffp in room before they cut. keep her asleep with a little bit of des/iso/sevo whatever. and try to dial in her baseline HR, BP with neo, esmolol, etc.

 

[Planktonmd]

97 y/o on plavix and uncontrolled HTN, ? CAD, etc....

before I put her under, I'm going to wait for that consult if there already is one consultant saying "not cleared" till seen by cardiology. go back to OR and adverse event occurs before being seen by cardiology and you may get to try and explain yourself on the stand. However, before cards writes any official notes, I want to have my input about what is said in that note.

she's getting that awake a-line before I put her under. She probably doesn't autoregulate so well and I want tight control of hemodynamics. Also the ortho guys will lose a bit of blood and think nothing of it... her EBV being dirt old/ 50kg and the fact that she may ooze with plavix makes me want to have that a-line for some frequent blood draws.

Don't like to do LA spinals on people that old anyhow.

So for her, 2iv's, a-line, if easy looking airway, maybe some lido, prop, fent, neo, while trying to maintain her baseline maps and then DL-> ett. blood and ffp in room before they cut. keep her asleep with a little bit of des/iso/sevo whatever. and try to dial in her baseline HR, BP with neo, esmolol, etc.

You are kidding aren't you?
This is an ORIF of a hip on a 97 Y/O that's going to die if you don't fix her hip.
You don't need a cardiologist to tell you she has CAD , some valvular disease, systolic hypertension, severely sclerotic arteries, and possibly some pulmonary fibrosis.....
I can almost guarantee that she has all these things and a few more.
I tend to be pretty conservative but here there is only one answer:
Fix the hip before she dies of complications and get her back to where ever she belongs before they manage to kill her.

 

[anesthesia11230]

The patient did well.

Just looking over this post once more. Actually impressed by the response. Nice to hear the collective minds of anesthesiologists. I did take notice that most people chose to induce with propofol.

I didnt see much mention of ETOMIDATE...and particular reasons (im aware of possible adrenal suppresion [even after one dose], and myoclonus)?

From initial impression of this old frail lady...was that she was extremely dry. Usually with hypovolemic sick patients I try to stay clear of propofol and lean towards etomidate...i didnt notice this trend on this thread.

In regards to maintenance of anesthesia...she was rather stable on volatile anesthetics (sevo) and even though she theoretically has decreased MAC requirements due to age...I had her about 0.8MAC throughout just to keep the blood pressure from being in 200's systolic

thanks
---------------------------------------------------
http://www.02demand.com
online community of clinical excellence in anesthesia

 

[anesthesia11230]

retrospect should have just given more beta blockers to control the BP (hemodynamics)

 

[Planktonmd]

The patient did well.

Just looking over this post once more. Actually impressed by the response. Nice to hear the collective minds of anesthesiologists. I did take notice that most people chose to induce with propofol.

I didnt see much mention of ETOMIDATE...and particular reasons (im aware of possible adrenal suppresion [even after one dose], and myoclonus)?

From initial impression of this old frail lady...was that she was extremely dry. Usually with hypovolemic sick patients I try to stay clear of propofol and lean towards etomidate...i didnt notice this trend on this thread.

In regards to maintenance of anesthesia...she was rather stable on volatile anesthetics (sevo) and even though she theoretically has decreased MAC requirements due to age...I had her about 0.8MAC throughout just to keep the blood pressure from being in 200's systolic

thanks
---------------------------------------------------
http://www.02demand.com
online community of clinical excellence in anesthesia

If you believe a patient is "Hypovolemic" then give them volume not Etomidate.
The verdict is still pending on Etomidate and increased mortality in the critically ill even after one single dose.
That said, you can use etomidate but small dose etomidate is a lousy induction agent for inserting an LMA, of course you can patch any shaky anesthetic with muscle relaxants and end up with a century old little lady who just wouldn't breath that much at the end or just give propofol and a little pressor, insert an LMA and call it a day.
Why many people seem to want to stick an ETT i this poor woman?

 

[Anesthesia1979]

You are kidding aren't you?
This is an ORIF of a hip on a 97 Y/O that's going to die if you don't fix her hip.
You don't need a cardiologist to tell you she has CAD , some valvular disease, systolic hypertension, severely sclerotic arteries, and possibly some pulmonary fibrosis.....
I can almost guarantee that she has all these things and a few more.
I tend to be pretty conservative but here there is only one answer:
Fix the hip before she dies of complications and get her back to where ever she belongs before they manage to kill her.

No kidding here... I agree that the hip should be fixed urgently and that's why I want to talk with cards about the patient before they write down their recs.

There is already documentation in the chart saying that this patient should not go to surgery till seen by the heart docs. I'm fine with taking patients back that are true emergencies, but this is not an emergency. It is an urgent case; therefore I'm cool with them seeing her, but I want to help them help me help the patient.

If she tanks on the table without them seeing her, you have no leg to stand on in court. That being said, case wouldn't be worth any lawyer's time. I mean how much earing capacity does a 97 y/o have?

 

[militarymd]

No kidding here... I agree that the hip should be fixed urgently and that's why I want to talk with cards about the patient before they write down their recs.

There is already documentation in the chart saying that this patient should not go to surgery till seen by the heart docs. I'm fine with taking patients back that are true emergencies, but this is not an emergency. It is an urgent case; therefore I'm cool with them seeing her, but I want to help them help me help the patient.

If she tanks on the table without them seeing her, you have no leg to stand on in court. That being said, case wouldn't be worth any lawyer's time. I mean how much earing capacity does a 97 y/o have?

97 year olds "tank" all the time....day in / day out....with or without a broken hip....

They are at higher risk of dying lying in their hospital beds waiting for the heart doctors to see them then they are in the OR where one of us are sitting there watching them continuously .

 

[epidural man]

The patient did well.

J

I didnt see much mention of ETOMIDATE...and particular reasons?

thanks
---------------------------------------------------
http://www.02demand.com
online community of clinical excellence in anesthesia

Yeah....because etomidate sucks.

 

[FlacoFlo]

The first snag is allowing the Orthopod to influence your thinking about her general medical issues!!

Famous quote from Ortho attending at our facility..."I'm just a simple man, I don't know much other than, bone broke... me fix!!"

There is no substitute for an in-person physical assessment of her cardiac status. If she has heart failure with acute exacerbation then sure her RCRI goes up, otherwise as Mil stated... she at risk for a poor outcome just due to her age!

Definitely a good case to discuss here!