Should I stop Plavix for orthopedic surgery?

A 60 year old woman with a stroke five years ago, who has been on Plavix ever since, gets hospitalized with a broken arm after a fall (it’s been icy this winter!). The orthopedics resident asks you if it’s okay to hold the Plavix, since they’re worried about her bleeding risk in the OR. “For ambulatory surgery,” he says, “We tell them to stop Plavix for 5 days before the procedure.”

Although there are some pretty solid recommendations on aspirin and warfarin in the perioperative setting, there aren’t clear guidelines for Plavix and DOACS….especially when you consider that orthopedic procedures have different bleeding risks than neurosurgical procedures than ophthalmologic procedures. One study of 40 patients undergoing hip fracture surgery reported no difference in bleeding between patients on Plavix versus those who were not. This systematic review of nine studies concludes that delaying hip fracture surgery for Plavix washout did not decrease bleeding and led to more post-op complications.

The American Academy of Neurology sought to provide clarity in this 2013 statement. They stated that while aspirin seems to increase bleeding risk for orthopedic surgeries (but not other kinds of procedures!) there was “insufficient evidence” to make a confident statement about Plavix. However they did point out that when bleeding did occur, most of the time it was mild–but when clotting occurred (like a stroke or PE), it was more morbid.

NB: however, Plavix is known to increase the risk of potential serious complications in spinal anesthesia. You probably want to avoid that. That being said, nothing is impossible, and there are cases of using platelet transfusions during spinal anesthesia to get people on Plavix through the case. It has been generally concluded that aspirin and spinal anesthesia are fine.

Conclusion: there is no one correct answer. For the woman above, if she just had drug-eluting stents put in last week, you should not stop the Plavix (and probably should not do surgery without talking with her cardiologist). If she’s been on Plavix for 5 years, and the surgery is going to be long and complicated, then it might be okay to hold it for a few days? Maybe? I probably wouldn’t because my personal opinion is, bleeding eventually stops, but a clot causes permanent damage. The orthopedics resident is right that holding Plavix for 5 days is general practice (although not clear where the evidence for this comes from). However, that’s in non-hospitalized patients who are functional enough to get to their scheduled surgery and go home after.

What do I do if a trach gets dislodged?!

A nurse runs into the workroom: “Ms. X’s trach is two inches out! She’s desatting to the 70’s on 60% FiO2!”

What do you do for a dislodged trach? This is the situation I faced a week ago, on a patient who wasn’t mine on the floor where I was working.

First, to clarify, dislodged=trach partially out of the stoma, decannulated=trach is all the way out of the stoma. Immature stoma is <1 week, mature stoma >1 week.

I love this slide from Vanderbilt, because it works for me, personally: keep it simple
  1. Your nurses and respiratory therapists are your life line!! Most institutions have protocols to page Anesthesia or a surgical team of some kind for these situations.
  2. Bag valve mask=Ambu bag: whatever you call it, if a patient with a trach is in distress, stabilize them with manual respiration. Apply the bag to the trach itself. If you meet “resistance” while bagging, STOP. It indicates either the trach is in a false tract, or there’s an obstruction, like a plug or extra tissue. (If it’s a false tract, you might be able to feel subcutaneous crepitus develop during bagging!)
  3. If bagging the trach doesn’t work, apply the bag to the patient’s mouth for face bag ventilation. The one caveat is laryngectomy patients: their mouths are not connected to the rest of their airways.
  4. Remove the inner cannula. Insert the suction catheter. If the catheter quickly draws back secretions, it’s still in the right place. If it doesn’t, the trach might be in a false tract.
  5. If you want to be fancy and have the skills, a fiberoptic scope can be passed from the mouth or through the stoma to look for problems.
  6. If the stoma is mature, in an emergency you can replace the trach with one that’s the same size or one size smaller. However, if the stoma is immature, the rate of closure is very high–up to 50% of the hole can close within 12 hours!
  7. Therefore, when dislodgement and definitely decannulation happens in an immature stoma, you may have to reintubate and wait for the surgeons to repair the stoma and reinsert the trach.

In my patient’s case, we ended up bagging her by mouth until respiratory therapy fiddled around with her trach enough to confirm it was in the right place and secured it with the trach collar. Stabilization is always #1! It turned out the patient had a large gap in her stoma, making the trach loose/malpositioned. The thoracic surgery team came by and put in a stitch to close the gap.

References:

Who needs to be on stress dose steroids and how do you taper them?

This post is about perioperative stress dose steroids, for adult patients, only. 

Who is at risk for perioperative adrenal insufficiency? The goal of stress dose steroids is to prevent hypotension and adrenal crisis/shock. The Society of Hospital Medicine (in one of their great learning modules), states: 

  • Low risk: <5 mg prednisone daily or ❤ weeks of prednisone over the past year
  • Moderate risk: >5 mg prednisone for >3 weeks in the past year
  • High risk: >20 mg prednisone daily for >3 weeks in the past year
  • Obviously, someone with primary adrenal insufficiency is the highest risk. 

What kind of steroid should be used? IV hydrocortisone is the most physiologic (+mineralocorticoid effect) and should be used until the patient can be transitioned back to prednisone/oral steroids. This letter makes an argument for dexamethasone that is interesting–I myself have never seen dexamethasone used for this indication, though. 

Does the kind of surgery affect whether someone should get stress dose steroids? Yes. 

  • Low stress: local anesthesia, ophthalmologic procedures, some small joint or hernia surgeries <1 hour
  • Moderate stress: general anesthesia, open procedures (hysterectomy, hemicolectomy)
  • High stress: lengthy, complex surgeries (CABG, pancreatectomy)
  • Patients at moderate-high risk undergoing moderate-high stress surgeries should be given stress dose steroids in the perioperative period. (Take this with a grain of salt–the objective evidence is very limited and there are good arguments for being even more conservative and only giving steroids to patients at high risk.)
    • Should you test for HPA axis suppression prior to surgery? If the patient is at moderate risk and undergoing moderate or high stress surgery, and you have the time to wait on results, then sure, you can. What test should you use? You can probably get away with an AM cortisol, although the cort stim test is more accurate

How the heck do I taper stress dose steroids? Stress dose steroid tapers, like ALL steroid tapers, are made up. We as a medical community prescribe tapers based on what “sounds reasonable.” What is usually reasonable is something along the lines of: 

  • Moderate stress surgery: 50 mg IV hydrocortisone x1 –> 25 mg Q8H x24-48 hours –> 10 mg prednisone x3-4 days –> usual dose
  • High stress surgery: 100 mg IV hydrocortisone x1 –> 50 mg Q8H x24-48 hours  –> 20 mg prednisone x3-4 days –> 10 mg prednisone x3-4 days –> usual dose 

Some people would advocate going straight from IV hydrocortisone back to the home dose, which is fine if the patient looks clinically well. Patients at higher risk of complications from steroids (hyperglycemia, fluid retention, agitation) should be tapered more quickly and patients at higher risk of adrenal insufficiency should be tapered more slowly.

Can you use methadone to prevent opiate withdrawal?

The situation: a young woman with opiate use disorder comes into the hospital with a broken arm after a car accident. She tells you she has been been buying methadone off the street and taking 60 mg a day. How do you manage this patient’s pain regimen and what can you do to prevent opiate withdrawal?

Methadone is typically used for maintenance therapy for opiate use disorder (OUD) or chronic pain. If it is for OUD, they must receive their doses from a methadone clinic. You should always try to call the clinic to verify the correct dose. In this patient’s case, she was buying methadone on her own. Therefore, the first step is to do a urine tox test–if the patient has been using methadone in the past week, it should be positive. If she is negative, it is not a good idea to start methadone unless she’s having withdrawal symptoms.

A patient’s home methadone dose does not provide acute pain control. Patients undergoing surgery can continue their methadone perioperatively. A patient who comes in on methadone (or suboxone, for that matter) needs the same kind of pain management as everyone else. For the patient above with the broken arm, you should still start Tylenol, NSAIDs if possible, and opiates like oxycodone or dilaudid for severe breakthrough pain.

Methadone is effective for preventing withdrawal symptoms in the inpatient setting. This Cochrane review shows that compared to placebo, tapered doses of methadone helped prevent withdrawal symptoms. There is no universal methadone tapered dose protocol. This American Pain Society sheet states methadone can be safely and rapidly tapered in 7-14 days. This pamphlet created by Pain Topics (and written by a Univ. Iowa pharmacist) has helpful information on short and long tapers. In general, you want to get the patient to reduce their dose by at most 25% every few days, end on a dose of 10 mg daily, and then stop completely.

For management of symptoms like sweats, muscle cramps, and nausea, check out this sister post.

How long does this person have to be NPO for?

Being NPO for an add-on surgical case (only to be told at 5 PM that there’s no chance the case will happen today) is a low-grade form of torture, and patients are always anxious to know when and if they can even have a little bit of water for their parched mouths. The nurse wants to know what time Mr. Smith should get his aspirin with a little apple juice if the case is scheduled for 11 AM. What’s the answer?

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Nicely prepared table from the learning module “Anesthesia for Internists” from the Society of Hospital Medicine

How to manage chest tubes (5-minute version)

I am no expert in chest tubes, and will add the caveat that for this particular post I really hope everything is correct! If it’s not, let me know! See this post on the different kinds of chest tubes. This is a great but long nursing resource from RN.com.

You’ve placed a chest tube: great! Now you hook it up to some weird box thing that is called a drainage system…now what? Knowing how chest tubes used to work helps you understand the box thing.

This picture is taken from a truly excellent little video on how chest tube drainage works:

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ThScreen Shot 2017-01-26 at 6.01.21 PM.pngere used to be 3 separate bottles hooked up to the chest tube itself: Bottle #1 is where the patient’s empyema fluid or blood leaked into. Bottle #2 is the waterseal: air is forced to travel through water and can only move in one direction (it cannot move back into the patient). Bottle #3 sets suction power based on how much water is in the bottle–more water=less suction, less water=more suction, and you need to make sure the suction power is just right. You can see how the drainage system has evolved over time on the right.

Should patients be “placed to waterseal” or “placed to -20 suction?” 

“Place to waterseal”= don’t be too crazy with drainage, which is appropriate for most pleural effusions or a mild pneumothorax. If the lung is not fully expanded, you can “turn up the suction.”If you apply suction too aggressively, you put the patient at risk for re-expansion pulmonary edema.

How do I know if there is an “air leak” and what the heck does it mean? 

An air leak is present if there is bubbling in the waterseal chamber when the suction is clamped/on waterseal–this indicates there is still air flowing from the chest to the tube. Positive pressure coming from the pleural space=air getting into the pleural space. Intermittent bubbling with expiration (when pleural pressure is highest in the non-ventilated patient) may be normal, but a continuous air leak is pathological and means the patient is not ready to have their chest tube pulled! 

You can “clamp” the tubing, which should stop an air leak. If the air leak persists even with clamping, consider:

  • ruptured bleb (severe emphysema)
  • simple traumatic pneumothorax (from placing the chest tube)
  • a leak in the actual tubing system
  • mechanical ventilation (may see decreased tidal volumes, failure of PEEP increase)
  • bronchopleural fistula (usually more severe or continuous)
  • lung entrapment vs. trapped lung

NB: if your patient has a persistent air leak, think twice about pulling their chest tube because if you do, you may cause a recurrent pneumothorax.

What is “tidaling?” 

You may see movement in the waterseal chamber with respiratory variation. It’s the water being sucked back towards the lung with inspiration due to negative inspiratory pressure. (In mechanically ventilated patients, it’s the opposite.)

How do I know when the tube can be taken out? 

In a 2013 study out of Michigan State, the team found it is reasonable to remove chest tubes when drainage <200 ml/day, on waterseal, with no air leak. In stable patients on the floor, theoretically you don’t need a chest x-ray after removal, but given our litigious society, everyone gets one. In mechanically ventilated patients, you should get a chest x-ray 1-3 hours after removal. However there is no need for regular surveillance chest imaging while a patient has a chest tube in. 

What do I do if the tube falls out? 

Use common sense: cover the area and prepare to re-insert a chest tube. Maintain sterility. The patient is at risk of a tension pneumothorax, so someone should stay with them for close monitoring. More troubleshooting at this nursing website.