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  • Another case for SRNAs- thoracotomy for RU lobectomy



    I have a case this week and am lucky enough to have a heads up to patient and his health history.

    68 year old male for thoracotomy for right upper lobectomy for lung ca.

    PMH: HTN- on lisinopril and metoprolol
    CAD- CABG 2010 then stents x4 2013 (BMS)
    NIDDM-glyburide hgb a1c 7.0

    PSH: TKA
    CABG
    CARDIAC stents
    AICD

    I am reviewing the chart and see that he had PTCA and stenting x4 in April after ACS. Recommendation from cardiology was rather vague at least 6 months of Plavix, would prefer 1 year Plavix and ideally stay on Plavix indefinitely due to complicated stenting. Wtf? Thoracic surgery requiring pt be off Plavix ok to stay on ASA.

    Further review indicates pt had cardiac arrest x2 one month ago at outside hospital requiring AICD placement.

    What would be your plan for this patient ?
    This article was originally published in forum thread: Another case for SRNAs- thoracotomy for RU lobectomy started by nurserebecca View original post
    Comments 49 Comments
    1. nurserebecca's Avatar
      nurserebecca -
      Btw, 1.5 ppd smoker for 40+ years.
    1. RAYMAN's Avatar
      RAYMAN -
      PPP....call hospice
    1. armygas's Avatar
      armygas -
      Quote Originally Posted by RAYMAN View Post
      PPP....call hospice
      Put the DLT in and grab a good rope and make it "8 seconds"
    1. nurserebecca's Avatar
      nurserebecca -
      Quote Originally Posted by RAYMAN View Post
      PPP....call hospice
      Ray
      "PPP"?????
    1. gaspass3's Avatar
      gaspass3 -
      Ben-Gay topically and IV Ofirmev

      Sent from my SAMSUNG-SGH-I747 using Tapatalk
    1. armygas's Avatar
      armygas -
      Quote Originally Posted by nurserebecca View Post
      Ray
      "PPP"?????
      Piss Poor Protoplasm
    1. nurserebecca's Avatar
      nurserebecca -
      Quote Originally Posted by gaspass3 View Post
      Ben-Gay topically and IV Ofirmev

      Sent from my SAMSUNG-SGH-I747 using Tapatalk
      Lol
    1. RAYMAN's Avatar
      RAYMAN -
      Quote Originally Posted by armygas View Post
      Piss Poor Protoplasm
      This
    1. Burnt2's Avatar
      Burnt2 -
      If the patient is on plavix, cancellectomy and clarification from cardiology.

      If plavix was held, proceed. I'd consider a platelet function test just for fun.

      Either way, cardiology should have a box that was checked "cleared" or another that says "not cleared", for the legal protection aspects.
    1. armygas's Avatar
      armygas -
      Quote Originally Posted by Burnt2 View Post
      If the patient is on plavix, cancellectomy and clarification from cardiology.

      If plavix was held, proceed. I'd consider a platelet function test just for fun.

      Either way, cardiology should have a box that was checked "cleared" or another that says "not cleared", for the legal protection aspects.
      I would love peeps to work at a "for profit" hospital------- nothing gets cancelled. The private practice ACT setting in a for profit hospital----- you are best served to be at your best for the patients because 99% of the time you will do the surgery.
    1. armygas's Avatar
      armygas -
      This is an example of "for profit". The dynamics are way way different trust me.

      http://www.iasishealthcare.com/

      hospitals
      http://www.iasishealthcare.com/hospitals/
    1. gaspass3's Avatar
      gaspass3 -
      Quote Originally Posted by Burnt2 View Post
      If the patient is on plavix, cancellectomy and clarification from cardiology.

      If plavix was held, proceed. I'd consider a platelet function test just for fun.

      Either way, cardiology should have a box that was checked "cleared" or another that says "not cleared", for the legal protection aspects.
      It is a cancer surgery. Do we have the luxury of waiting for a traditional clearance? At some point the case will have to proceed, at least most likely. It seems like just coordinating the best timimg for anti-coagulants and stent preservation vs surgical bleeding (and even an epidural from us for that matter).

      Sent from my SAMSUNG-SGH-I747 using Tapatalk
    1. armygas's Avatar
      armygas -
      Quote Originally Posted by gaspass3 View Post
      It is a cancer surgery. Do we have the luxury of waiting for a traditional clearance? At some point the case will have to proceed, at least most likely. It seems like just coordinating the best timimg for anti-coagulants and stent preservation vs surgical bleeding (and even an epidural from us for that matter).

      Sent from my SAMSUNG-SGH-I747 using Tapatalk
      you have been around
    1. nurserebecca's Avatar
      nurserebecca -
      Hoping for some students to weigh in on their plan... Also what do you want to do regarding recent cardiac arrest/ AICD?
    1. Burnt2's Avatar
      Burnt2 -
      Quote Originally Posted by armygas View Post
      I would love peeps to work at a "for profit" hospital------- nothing gets cancelled. The private practice ACT setting in a for profit hospital----- you are best served to be at your best for the patients because 99% of the time you will do the surgery.
      Sorry I didn't see for profit hospital listed in the H&P. Part of being at my best is in preop having a conversation with the surgeon about the urgency of the case. I think that's where many people just don't have the stones to say "lets delay", or "let's cancel".

      Quote Originally Posted by gaspass3 View Post
      It is a cancer surgery. Do we have the luxury of waiting for a traditional clearance? At some point the case will have to proceed, at least most likely. It seems like just coordinating the best timimg for anti-coagulants and stent preservation vs surgical bleeding (and even an epidural from us for that matter).

      Sent from my SAMSUNG-SGH-I747 using Tapatalk
      I can transfuse blood, sure, but there's different levels of urgency with these cases, and if the patient is still on plavix I'll talk with the surgeon about it. Ultimately if he feels it needs to go I'll do it, but if it's non emergent or if the plavix can be stopped per cardiology since it's been 7 months we can bring him back in a week and perform a safer surgery. Epidural is optional with coagulation issues....I can do intercostal blocks.

      I think Army just went ballistic over in another thread over the risks of transfusing, although I wasn't reading too closely, so lets just pretend that stuff was already said on this thread.

      I work at a CHS hospital, BTW. It doesn't get more for profit than that, and you're right...the kinds of unprepped patients that are sometimes shoved through the system is ridiculous.
    1. armygas's Avatar
      armygas -
      Quote Originally Posted by Burnt2 View Post
      I work at a CHS hospital, BTW. It doesn't get more for profit than that, and you're right...the kinds of unprepped patients that are sometimes shoved through the system is ridiculous.
      People are gonna have to deal with this more and more as competition in healthcare changes. It is a reality. So best be prepared to take anything back or lose your job. Tough choice but a reality. The only thing I have seen recently is NPO status delaying a case. but when it comes to anticoags---- the response in the ACT is "do a general".
    1. RAYMAN's Avatar
      RAYMAN -
      Quote Originally Posted by armygas View Post
      People are gonna have to deal with this more and more as competition in healthcare changes. It is a reality. So best be prepared to take anything back or lose your job. Tough choice but a reality. The only thing I have seen recently is NPO status delaying a case. but when it comes to anticoags---- the response in the ACT is "do a general".
      Chart surgeon notified of plavix and rock on. NPO only delays depending on time of day....later in the day then it becomes an emergent case.
    1. ativan halen's Avatar
      ativan halen -
      Quote Originally Posted by nurserebecca View Post
      I have a case this week and am lucky enough to have a heads up to patient and his health history.

      68 year old male for thoracotomy for right upper lobectomy for lung ca.

      PMH: HTN- on lisinopril and metoprolol
      CAD- CABG 2010 then stents x4 2013 (BMS)
      NIDDM-glyburide hgb a1c 7.0

      PSH: TKA
      CABG
      CARDIAC stents
      AICD

      I am reviewing the chart and see that he had PTCA and stenting x4 in April after ACS. Recommendation from cardiology was rather vague at least 6 months of Plavix, would prefer 1 year Plavix and ideally stay on Plavix indefinitely due to complicated stenting. Wtf? Thoracic surgery requiring pt be off Plavix ok to stay on ASA.

      Further review indicates pt had cardiac arrest x2 one month ago at outside hospital requiring AICD placement.

      What would be your plan for this patient ?
      Pre-op echocardiogram to evaluate current cardiac function

      EKG/Baseline CBC + Plt, CMP, PT/PTT/INR, Type and Screen

      Discuss continuing plavix and aspirin with thoracic surgery d/t high risk for re-occlusion of complicated stents
      --avoid epidural d/t risk for bleeding and subsequent hematoma
      --avoid Toradol d/t risk for bleeding and blackbox warning on CABG patients for re-occlusion
      --Type and Screen
      --Have platelets/PRBCs/FFP/Cryoprecipitate available for transfusion

      De-Activate AICD but have defibrillator in OR d/t recent cardiac arrests
      --re-activate immediately post-operatively while in OR

      General Anesthesia

      Arterial Line and at least two 14 or 16 gauge IVs (CVC?)

      Intra-op Cardiac Isoenzymes and CBC + Plt

      Probably way off, but really interested in the plan here.
    1. armygas's Avatar
      armygas -
      Quote Originally Posted by RAYMAN View Post
      Chart surgeon notified of plavix and rock on. NPO only delays depending on time of day....later in the day then it becomes an emergent case.
      yessir!
    1. Teillard's Avatar
      Teillard -
      Quote Originally Posted by nurserebecca View Post
      I have a case this week and am lucky enough to have a heads up to patient and his health history.

      68 year old male for thoracotomy for right upper lobectomy for lung ca.

      PMH: HTN- on lisinopril and metoprolol
      CAD- CABG 2010 then stents x4 2013 (BMS)
      NIDDM-glyburide hgb a1c 7.0

      PSH: TKA
      CABG
      CARDIAC stents
      AICD

      I am reviewing the chart and see that he had PTCA and stenting x4 in April after ACS. Recommendation from cardiology was rather vague at least 6 months of Plavix, would prefer 1 year Plavix and ideally stay on Plavix indefinitely due to complicated stenting. Wtf? Thoracic surgery requiring pt be off Plavix ok to stay on ASA.

      Further review indicates pt had cardiac arrest x2 one month ago at outside hospital requiring AICD placement.

      What would be your plan for this patient ?
      So where is he on his plavix? Some issues are rebound hypercoaguable blood from plavix withdrawal and hypercoaguable blood from his cancer. Aspirin helps, but if the stenting was complicated, he's at higher risk despite having BMS's. That said, and assuming there is a compelling case for not delaying (the guy will be a big risk regardless of when you do him) I'd agitate for plavix bridging therapy and getting him back on it ASAP post surgery. VATS not an option?