What would you do?

[urge]

50 something y/o male with hx of ischemic cardiomyopathy(EF 30%) for the past few years on usual meds and an ICD, had a MI 10 days ago treated in cath lab and stented. Doing well now. Ambulating(let's call it 4 mets). No more chest pain. Comes today to ER for flank pain dx as ureteral stone. Urologist wants to do cysto for stone retrieval.

Do you do the case? Should you wait? Why?

If you decide to do it, how?

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[Noyac]

This is a GA case due to antiplatelet meds for the stent. I would continue these meds throughout the surgery and proceed. This is more than likely a DES (drug eluting stent). At 10 days the type doesn't really matter to me. Drug eluting or not, it's risk of thrombosis is essentially the same.

Things you want to know. Where is the stent, LAD? How much myocardium is at risk if the stent thrombosis?

Can we put him on Heparin anyone? Why or why not?

 

[Planktonmd]

50 something y/o male with hx of ischemic cardiomyopathy(EF 30%) for the past few years on usual meds and an ICD, had a MI 10 days ago treated in cath lab and stented. Doing well now. Ambulating(let's call it 4 mets). No more chest pain. Comes today to ER for flank pain dx as ureteral stone. Urologist wants to do cysto for stone retrieval.

Do you do the case? Should you wait? Why?

If you decide to do it, how?

Wait for what?
Make sure the Urologist understands that this guy is on Plavix and just give Propofol + LMA + Sevo.
If bad hematuria post op give some platelets.

 

[urge]

Ok. Did prop lma sevo. I'm just asking because my CRNA was crapping her pants about this case. She called me 4 times to talk me into canceling the case.I was wondering if it is me not being very impressed by a recent MI or is it more or less standard.

The only downside about a recent MI that I could think of is the increased chance of an arrhythmia. 10 days out should be low I think.

Is there anyone who would not do the case?

 

[dhb]

50 something y/o male with hx of ischemic cardiomyopathy(EF 30%) for the past few years on usual meds and an ICD, had a MI 10 days ago treated in cath lab and stented.

How do you know they stented the vessel responsible for the MI? ICM and 30% EF he must have a crappy cath... Other than that it's a low risk procedure on a asymptomatic (treated) patient so it should be strait to OR

 

[Tenesma]

dude this ain't even tough - tell the CRNA this what anesthesia is about: making the tuff calls...

as long as patient and urologist understand the risks then i would do the following:

1) teach urologist how to do a penis block
2) tell urologist: good luck with cysto...

if the urologist didn't like that idea, i would probably do prop/lma/remifentanil infusion with light prop boluses... and watch IV fluids...

 

[militarymd]

wish I had something to add.

 

[Noyac]

1) teach urologist how to do a penis block
2) tell urologist: good luck with cysto...

if the urologist didn't like that idea, i would probably do prop/lma/remifentanil infusion with light prop boluses... and watch IV fluids...

Ain't nobody doing a cysto on me with a penis block and therefore not on my pts either. But I'll give you credit for creativity.

Sure is a lot of Remi flowing out there. Maybe I need to re-explore this stuff. On second thought, Nope.

 

[mille125]

i am definitely not a CRNA supporter, but he or she was probably worried about the very very high chance of in-stent thrombosis when surgery is performed within the first thirty days of stent placement. There is good evidence in the literature of morbidity and mortality in this condition (last paper that i recall suggested 30 or 40% risk of death or massive MI). In general these patients should avoid the OR in the first thirty days...

 

[huktonfonix]

Sure, they SHOULD avoid surgery when possible. Which brings up the question is this elective surgery? IS the urologist worried about complete blockage, hydronephrosis, infection, etc..? If the risks are great enough and the stone is not likely to spontaneously pass then he will be going to the OR anyway. No point in holding up the surgery for 3 more weeks. Its an LMA for him. I would prefer to do this at a center with a cath lab however in case of thrombosis.

 

[Strength&Speed]

i am new to gas forum, but I like it. So sorry for my newbieness. Why does everyone say LMA...?

 

[Noyac]

i am definitely not a CRNA supporter, but he or she was probably worried about the very very high chance of in-stent thrombosis when surgery is performed within the first thirty days of stent placement. There is good evidence in the literature of morbidity and mortality in this condition (last paper that i recall suggested 30 or 40% risk of death or massive MI). In general these patients should avoid the OR in the first thirty days...

Do you consider a cysto for stone retrieval to be a surgery that will increase inflamatory mediators like other surgeries which are the reason for the stent thrombosis post-op?

I don't and therefore some surgeries are safer than others in these pts for that reason. I'm not saying that I have the answer since I haven't seen these mediators measured after a cysto but I believe they would be small. I would still continue the anti-platelet meds.

So nobody wanting to put this guy on heparin?

 

[urge]

So nobody wanting to put this guy on heparin?

I wouldn't. The therapy after stents is plavix and asa, not lovenox or coumadin. I would just make sure he continues his antiplatelet meds, which he was up until sirgery. Hope he is still.

 

[mille125]

i wish i had the reference. I remember that the data was really compelling. 40 patients had surgery within four weeks of stent placement. 11 died and 13 had massive MI from in-stent thrombosis. That is 24/40 with serious complications. 50% were on plavix or plavix plus aspirin (indicating that plavix gave no protection).


to me this case sounds elective, but I was not there and I cannot comment on all of the medical issues at stake.

for those who are interested i think that this paper was in 2003...

 

[militarymd]

this wasn't in the anesthesia literature....I think it was Circulation.

But weren't the surgeries...high risk surgeries?

i wish i had the reference. I remember that the data was really compelling. 40 patients had surgery within four weeks of stent placement. 11 died and 13 had massive MI from in-stent thrombosis. That is 24/40 with serious complications. 50% were on plavix or plavix plus aspirin (indicating that plavix gave no protection).


to me this case sounds elective, but I was not there and I cannot comment on all of the medical issues at stake.

for those who are interested i think that this paper was in 2003...

 

[Planktonmd]

i wish i had the reference. I remember that the data was really compelling. 40 patients had surgery within four weeks of stent placement. 11 died and 13 had massive MI from in-stent thrombosis. That is 24/40 with serious complications. 50% were on plavix or plavix plus aspirin (indicating that plavix gave no protection).


to me this case sounds elective, but I was not there and I cannot comment on all of the medical issues at stake.

for those who are interested i think that this paper was in 2003...

One would wonder:
Which is more dangerous to the patient:
The horrible pain of a kidney stone with associated catecholamine increase and the urinary infection causing generalized inflammatory syndrome or a 15 minutes minimally invasive procedure?
There is data showing increased mortality from surgery immediately after MI but this procedure can hardly be called surgery, it's a little bit more involved than placing a Foley, but not too far from it.
Evidence based medicine is great but we also need to use common sense.

 

[urge]

Mille, is this what you are talking about? http://content.onlinejacc.org/cgi/content/full/49/1/122

"In recent studies, an association between early noncardiac surgery after PCI and adverse cardiac outcome has been reported as well (1,2,5). However, these reports did not include the use of drug-eluting stents. The excessive risk of early surgery after PCI might be attributable to the high risk of in-stent thrombosis during the perioperative period. This thrombosis risk is possibly increased by the stress response to major surgery. The stress response includes sympathetic activation promoting shear stress on arterial plaques, enhanced vascular reactivity conducive to vasospasm, reduced fibrinolytic activity, platelet activation, and hypercoagulability. Because procoagulant clotting factors increase while fibrinolysis decreases, the surgical patient is in a hypercoaguable state. Furthermore, coronary stenting results in denudation of the endothelial surface. This might also contribute to the high risk of patients with early surgery because re-endothelization takes up to 8 weeks. This hypothesis is supported by our finding that all MACEs in the early-surgery group occurred in patients in whom antiplatelet therapy was discontinued, including 3 events in the 17 patients with bare-metal stents in whom antiplatelet therapy was discontinued and 2 events in 9 patients with drug-eluting stents without antiplatelet therapy. In contrast to our findings, Reddy et al. (5) did not show an association between discontinuation of antiplatelet therapy and perioperative MACEs in 56 patients with prior bare-metal stenting. This might have been attributable to the small number of events in their study."


http://circ.ahajournals.org/cgi/content/full/116/16/e378
"When possible, surgery should be delayed until the patient is outside the recommended period of dual antiplatelet therapy, as determined by the stent and lesion characteristics. This would mean that surgery should be delayed until 6 weeks after implantation of a bare-metal stent and 1 year after implantation of a DES. In reality, the recommendation for a 6-week delay with a bare-metal stent is to ensure that the patient completes a 4-week course of dual antiplatelet therapy because the patient will need 5 to 10 days (depending on the platelet half-life) for the effect of the antiplatelet agents to wear off before surgery.21 Patients in whom noncardiac surgery is carried out within these time periods are deemed at high risk of stent thrombosis. Patients in whom noncardiac surgery is performed outside these time periods may still be at high risk of stent thrombosis, depending on factors related to their coronary anatomy and their clinical characteristics. Stent thrombosis is more likely to occur in patients who have had stenting of ostial lesions, bifurcation lesions, lesions in small vessels, multiple lesions, or long lesions. In addition, patients with diabetes mellitus or renal impairment or patients in whom the indication for stenting was an acute myocardial infarction or an acute coronary syndrome are at higher risk of stent thrombosis."

Found a little gem(2007):
we have adapted a table from Albaladejo et al20 (2006)and incorporated the latest recommendations
http://circ.ahajournals.org/cgi/content-nw/full/116/16/e378/TBL2186852

Says for low risk of bleeding surgery it is ok to go to OR if antiplatelets are continued.

 

[Noyac]

I wouldn't. The therapy after stents is plavix and asa, not lovenox or coumadin. I would just make sure he continues his antiplatelet meds, which he was up until sirgery. Hope he is still.

Correct.

Heparin and coumadin are not anti-platelet meds.

 

[2ndyear]

i am new to gas forum, but I like it. So sorry for my newbieness. Why does everyone say LMA...?

Intubation is very stimulating leading to catecholamine release, increased afterload and heart rate. Basically everything you don't want to do in a patient with CAD and cardiomyopathy. Can it be done? Sure. Does it need to be, not always, hence the LMA. While this still requires an anesthetic induction, the absence of a big steel blade on the epiglottis and a large tube through the trachea makes it more appealing.

 

[dhb]

What's the incidence of resistance to plavix? 30%?

 

[Tenesma]

actually heparin does have anti-platelet effects - so not a bad idea... but the guy probably is on Plavix already... just tell the Uro not to nick the urethral meatus or bang up the prostate on his way in/out..

BUT, i would argue that cystoscopy is NOT really surgery... you aren't cutting up tissue etc...

and then the argument is: does anesthesia in of itself increase the risk of in-stent thrombosis.... i am not convinced of that...

and anesthesia is a lot less stressful (if done properly) then horrible renal colic...

the beauty of remi is that it gives such amazing control over the short amount of peri/intra-operative pain... you would love it --- i don't know about private practice costs of remi - but i don't know if costs really apply in this guy's case...

 

[mille125]

One would wonder:
Which is more dangerous to the patient:
The horrible pain of a kidney stone with associated catecholamine increase and the urinary infection causing generalized inflammatory syndrome or a 15 minutes minimally invasive procedure?
There is data showing increased mortality from surgery immediately after MI but this procedure can hardly be called surgery, it's a little bit more involved than placing a Foley, but not too far from it.
Evidence based medicine is great but we also need to use common sense.

Plankton, I really think that you would need to be there to fully comment on the risk/benefit ratio. Where is the stone located? What is the likelihood that it will pass on its own? How much pain is the patient truly having? Many stones do pass on their own.

There is no black and white. This is a gray area. However, the risks of anesthesia in a cardiac patient with a low EF and recent stents is not trivial. As you know , induction is a very precarious time and really makes the length of the procedure moot. All of us would agree that regional anesthesia is not an option.

 

[mille125]

actually heparin does have anti-platelet effects - so not a bad idea... but the guy probably is on Plavix already... just tell the Uro not to nick the urethral meatus or bang up the prostate on his way in/out..

BUT, i would argue that cystoscopy is NOT really surgery... you aren't cutting up tissue etc...

and then the argument is: does anesthesia in of itself increase the risk of in-stent thrombosis.... i am not convinced of that...

and anesthesia is a lot less stressful (if done properly) then horrible renal colic...

the beauty of remi is that it gives such amazing control over the short amount of peri/intra-operative pain... you would love it --- i don't know about private practice costs of remi - but i don't know if costs really apply in this guy's case...

in theory it is low risk...but what if there is a complication (which is always possible)

 

[Tenesma]

dude - you could slip on the floor in the cafeteria of your hospital - does that mean you don't grab lunch???

now, not only could you slip on the floor but you could also develop an intra-cranial bleed... and that could be complicated by a ventilator-pneumonia... and you could develop a pressur ulcer in the ICU... etc...

You are ALWAYS allowed to say that based on your professional opinion you don't feel comfortable doing the case unless the urologist documents in the chart that without stone extraction the patient is at risk for XYZ... that helps - a bit...

 

[mille125]

dude - you could slip on the floor in the cafeteria of your hospital - does that mean you don't grab lunch???

now, not only could you slip on the floor but you could also develop an intra-cranial bleed... and that could be complicated by a ventilator-pneumonia... and you could develop a pressur ulcer in the ICU... etc...

You are ALWAYS allowed to say that based on your professional opinion you don't feel comfortable doing the case unless the urologist documents in the chart that without stone extraction the patient is at risk for XYZ... that helps - a bit...

dude....what is your point?

 

[urge]

in theory it is low risk...but what if there is a complication (which is always possible)

Complications are always possible. Everyday I drive to the Hospital I risk my life. Hasn't stopped me from driving. The real question is how do we help pts best? Leaving pts with large ureteral stones (the small ones don't go to the OR) for fear of complications despite current recommendations saying that it's ok to proceed, as long as antiplatelets are still given, might not be in the pts best interest.

I'm actually glad I brought up this case and there was disagreement about it, since now I have evidence to back up my clinical common sense.

 

[mille125]

Complications are always possible. Everyday I drive to the Hospital I risk my life. Hasn't stopped me from driving. The real question is how do we help pts best? Leaving pts with large ureteral stones (the small ones don't go to the OR) for fear of complications despite current recommendations saying that it's ok to proceed, as long as antiplatelets are still given, might not be in the pts best interest.

I'm actually glad I brought up this case and there was disagreement about it, since now I have evidence to back up my clinical common sense.

you guys are taking what i said out of context....

Sure complications occur. Most of the time they are unplanned and unexpected. Handling these crises is what differentiates MD's from mid level providers. This is what we are trained for.


I was responding to a previous quote where it was suggested that you should "do the this case because it is likely to be short and may not be a real surgery". My point is that a short cysto can become much more involved in a hurry. What you would get in this circumstance would not be pretty. I would describe it as ubiquitous melancholy. This is something that you should want to avoid.


Obviously it is unwise to take an approach merely to avoid a possible complication. This case represents a gray area and there are no lines drawn in the sand. Each case should be taken individually. The original poster feels that in this patient that the case needs to go to benefit the patient. He would know best because he is standing in front of the patient.

 

[Noyac]

actually heparin does have anti-platelet effects - so not a bad idea... but the guy probably is on Plavix already....

Besides the occasional thromocytopenia, heparin is a very poor plt inhibitor unless combined with aspirin. If it was a better plt inhibitor we would be bridging these pts with heparin all the time. It may be better than nothing but thats about it.

Heparin inactivates thrombin and this not only prevents fibrin formation but also inhibits thrombin-induced activation of plts as well as factors V and VIII. Just not as well as plavix and these stents are just dying for some plts to stick to them.

But you are right that its necessarily a bad idea. Better than nothing.

 

[Bougie]

I agree with proceeding with this low risk surgery. BUT....if the guy ends up having an in-stent thrombosis a week later and croaks (cuz he couldn't afford his Plavix or whatever) does the judge point his finger at you???? What are the legal ramifications here?

 

[Pooh & Annie]

So there was NO CHANGE in his functional capacity? I wouldn't have too much of a problem with doing the case with the antiplatelets, but a guy with ICM with a PRE-INFARCTION EF of 30% can't tolerate much more damage. If his functional capacity changed at all I would start worrying about dysrhythmias, acute on chronic CHF... If he felt no change from before his baseline I would do the case