Challenging Cases in Perioperative Medicine

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Challenging Cases in Perioperative Medicine

• Margaret M. Beliveau MD
• General Internal Medicine
• Mayo Clinic,
• Rochester, Mn

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Disclosures

• No relevant industry conflict of interest
• I will not be discussing off-label use of drugs
• I have 2 teenage drivers, which resulted in all
  my hair turning grey

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Objectives

• Discuss the management of patients with cardiac
  stents in the perioperative setting
• Discuss the perioperative management of the frail
  elderly patient with multiple co-morbidities
• Discuss issues in hypertension management in the
  perioperative setting
• Discuss the perioperative management of patients
  with hemophilia

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Case 1

• A 70 year old man falls while out walking his
  dog. For the next week, his family notices
  progressive gait instability. After a second
  fall, they take him to the emergency room, where
  he is discovered to have a large right subdural
  hematoma.

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Case 1

• He had an ST elevation MI 4 months ago at an
  outside facility and a drug-eluting stent was
  placed (paclitaxel). No further information is
  available.
• He also has a history of recurrent DVT and PE has
  been maintained on warfarin
• Bipolar disorder

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Case 1

• Lexapro 20 mg by mouth daily
• Aspirin 325 mg by mouth daily
• Warfarin 4 mg by mouth daily
• Plavix 75 mg by mouth daily
• Atenolol 75 mg daily

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Case 1

• INR 2.9 on admission
• Plan for Burr hole evacuation of subdural
  hematoma

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Case 1

• In addition to stopping the warfarin, what do you
  tell the surgeon with regard to his medications?

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Case 1

• The patient should undergo the surgical procedure
  on aspirin and clopidogrel
• The aspirin should be stopped, but the
  clopidogrel should be continued
• The aspirin and clopidogrel can be interrupted
  for the surgical procedure
• The clopidogrel can be stopped, but the aspirin
  should be continued

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Case 2

• 72 yo man
• Nov. 2006- gross hematuria
• TURBT, muscle invasive bladder cancer
• Cystectomy recommended, but preoperative cardiac
  evaluation abnormal
• Radiation therapy, ended June 2007
• Feb. 2008- recurrent hematuria

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Case 2

• Chemotherapy given
• Ongoing hematuria, now transfusion dependent
• Proposed curative cystectomy

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Case 2

• March 2007- abnormal EKG on preoperative
  evaluation
• Coronary angiogram- CABG recommended, patient
  refused
• 15 bare metal stents placed
• July 2007- patient complains of fatigue
• Angiogram- restenosis

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Case 2

• 14 more drug eluting stents placed
• 5- LAD, 5- RCA, 4- circumflex
• March 2008- adenosine sestamibi positive for
  ischemia (severe left main disease), small area
  of infero-septal infarct
• Patient remains asymptomatic
• Cardiology evaluation benefits of surgery
  outweigh risks

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Case 2

• What do you tell the surgeon with regard to his
  medications?

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Case 2

• The patient should undergo the surgical procedure
  on aspirin and clopidogrel
• The aspirin should be stopped, but the
  clopidogrel should be continued
• The aspirin and clopidogrel can be interrupted
  for the surgical procedure
• The clopidogrel can be stopped, but the aspirin
  should be continued

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The Story of the Stent

• Bare Metal Stent (BMS) first introduced in the US
  in 1994
• Drug Eluting Stent (DES) became available in 2003
• Over 4 million stents (BMS and DES) placed
  annually worldwide

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The Story of the Stent

• DES are being deployed in 80-90 of coronary
  interventions in the US (the majority of these
  for off label indications)
• More than 6 million drug eluting stents have been
  placed since they became available in 2003

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FDA Indications for Use

• The CYPHER (Sirolimus-eluting Coronary Stent) is
  indicated for
• improving coronary luminal diameter in patients
  with symptomatic ischemic disease due to discrete
  de novo lesions of length 30 mm in native
  coronary arteries with reference vessel diameter
  of 2.5 mm to 3.5 mm.
• The TAXUS (Express Paclitaxel-Eluting Coronary
  Stent System) is indicated for
• improving luminal diameter for the treatment of
  de novo lesions 28 mm in length in native
  coronary arteries 2.5 to 3.75 mm in diameter.

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Off-Label Indications for Drug Eluting Stents

• 50-60 of DES are placed for off-label use

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Iakovou et al JAMA 2005Prospective observational
cohort of 2229 consecutive patients who had DES
placed
9 month followup
Subacute lt 30 Days
Late gt 30 Days
Cumulative incidence of stent thrombosis 1.3
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Iakovou et alJAMA 2005

• In this study, 29 of the patients who
  prematurely discontinued dual antiplatelet
  therapy developed stent thrombosis
• Case fatality rate for patients who developed
  stent thrombosis was 45
• These were all patients who had stent placement,
  not just patients undergoing non-cardiac surgery

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What Do You Recommend if a Patient with a Recent
Stent Needs Surgery?

• Approximately 5 of patients who undergo coronary
  stenting require noncardiac surgery within 1 year
  of stenting
• Fear of excessive bleeding leads to the generally
  accepted policy of discontinuing these agents
  7-10 days before elective surgery

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The Perfect Storm
Trouble
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Abrupt discontinuation of clopidogrel
Abrupt discontinuation of aspirin

• Rebound effect
• Significantly increased inflammatory
  prothrombotic state
• Significantly increased platelet adhesion and
  aggregation
• Excessive thromboxane A2 activity

• Surgical intervention with increased
  prothrombotic and inflammatory state
• increased cytokines, neuroendocrine inflammatory
  mediator release
• increased platelet adhesiveness and persistently
  high platelet counts
• increased release of procoagulant factors
• decreased or impaired fibrinolysis

Prothrombotic state with incompletely
endothelialized stent(s)
Stent thrombosis, MI, Death
Newsome LT Anesth Analg 2008 107570-90
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Anti-platelet Drugs

• Widely used for primary and secondary prevention
  of cardiovascular disease
• Plaque stabilization
• Used after placement of intracoronary stents to
  prevent thrombosis

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Anti-platelet Drugs

• Continuationgt increased risk of perioperative
  bleeding
• Interruptiongtrisk of stent thrombosis

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Anti-platelet Drugs

• Aspirin
• Thienopyridines (clopidogrel)
• GP IIb/IIIa receptor antagonists

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Anti-platelet Drugs

• Bleeding risks
• No large prospective randomized trials
• Aspirin risk of bleeding increased by a factor
  of 1.5, without increased morbidity or mortality
• Risk highest in specific procedures CABG,
  prostatectomy and intra-cranial neurosurgery

Chassot PG BJA 99316-28, 2007
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Anti-platelet Drugs

• Dual therapy ASA plus clopidogrel
• Moderate increase in surgical blood loss, but not
  in morbidity, mortality or surgical outcome
• Exception intracranial neurosurgery

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Anti-platelet Drugs

• Risks of maintaining
• Increased surgical blood loss
• Increased transfusion rate

• Withdrawal risks
• Rebound increased platelet adhesiveness
• Doubled infarction and death rate in acute
  coronary syndrome
• Increased risk of stent thrombosis with high
  mortality

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Risk of Stent Thrombosis

• High risk stents long, proximal, multiple,
  overlapping, small vessels, bifurcation
• High risk patients Low EF, diabetes
• High risk timing lt 6 weeks after bare metal
  stent lt 12 months after drug-eluting stent

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Risk of Stent Thrombosis

• If stent not completely endothelialized, risk of
  acute stent thrombosis increased
• Prothrombotic state induced by surgery

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Risk of Stent Thrombosis

• The most powerful predictor of acute stent
  thrombosis with BMS is time delay of lt 14 days
  between implantation and interruption of
  anti-platelet therapy

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Risk of Stent Thrombosis

• Drug-eluting stents adverse clinical events (MI,
  death) noted when patients stopped anti-platelet
  therapy prematurely

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The Perioperative Dilemma

• Discontinue antiplatelet drugs perioperatively
• Stent thrombosis
• MI
• Cardiac death

• Continue perioperative antiplatelet drugs
• Surgical bleeding

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The Perioperative Dilemma

• Based on currently available data, the risk of
  withdrawing anti-platelet drugs is greater than
  continuing them
• Withdrawal imposes perioperative cardiac death
  rate that is increased 5-10 times

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Chassot PG BJA 99316-28, 2007
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Society for Cardiovascular Angiography Clinical
Alert, Jan 2007
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Joint Advisory Recommendations and Noncardiac
Surgery

• Consider bare metal stent if patient requires PCI
  and is likely to require invasive or surgical
  procedure within next 12 months.
• Educate patient prior to discharge re risk of
  premature antiplatelet discontinuation.
• Instruct patient to contact treating cardiologist
  before antiplatelet discontinuation

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Joint Advisory Recommendations and Noncardiac
Surgery

• Healthcare providers who perform surgical or
  invasive procedures must be made aware of
  catastrophic risks of premature antiplatelet
  discontinuation and should contact the treating
  cardiologist to discuss optimal management
  strategy

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Joint Advisory Recommendations and Noncardiac
Surgery

• Defer elective procedures for which there is
  bleeding risk until completion of antiplatelet
  course
• 1 month bare metal stent
• 12 months drug eluting stent
• For patient with drug eluting stents who are to
  undergo procedures that mandate discontinuation
  of thienopyridine (e.g., clopidogrel), continue
  aspirin if at all possible and restart
  thienopyridine as soon as possible

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Joint Advisory Recommendations and Noncardiac
Surgery

• No evidence for bridging therapy with
  antithrombins, warfarin, or glycoprotein
  IIIB/IIIA agents

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Proposed Approach for Management of Dual
Antiplatelet Therapy with Previous PCI who
Require Surgery
Balloon Angioplasty
Bare-metal Stent
Drug-eluting Stent
lt365 Days
lt 30-45 Days
lt 14 Days
gt 14 Days
gt365 Days
gt 30-45 Days
Delay Elective or Non-urgent Surgery
Delay Elective or Non-urgent Surgery
Proceed to Operating Room with Aspirin
Proceed to Operating Room with Aspirin
Based on Expert Opinion, from the ACC/ AHA
guidelines, 2007
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Back to the patients

• Patient 1 Drug-eluting stent, DVT/PE, on
  warfarin, aspirin and clopidogrel, sub dural
  hematoma
• My recommendations Stop antiplatelet agents,
  restart aspirin 5 days after surgery if stable,
  restart clopidogrel as soon as possible after
  surgery (10 days-2 weeks per neurosurgeon)
• ? Loading dose (300 mg) of clopidogrel

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Case 1

• The patient should undergo the surgical procedure
  on aspirin and clopidogrel
• The aspirin should be stopped, but the
  clopidogrel should be continued
• The aspirin and clopidogrel can be interrupted
  for the surgical procedure
• The clopidogrel can be stopped, but the aspirin
  should be continued

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Back to the patients

• Patient 2 29 stents, locally invasive bladder
  cancer
• Underwent radical cystoprostatectomy, limited
  pelvic lymphadenectomy, and ileal conduit
  formation
• Aspirin and clopidogrel held prior to surgery
  (despite our recommendations)
• POD1

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Case 2

• The patient should undergo the surgical procedure
  on aspirin and clopidogrel
• The aspirin should be stopped, but the
  clopidogrel should be continued
• The aspirin and clopidogrel can be interrupted
  for the surgical procedure
• The clopidogrel can be stopped, but the aspirin
  should be continued

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Case 2

• However, the surgeon was not comfortable
  operating with aspirin and clopidogrel on board,
  and these were held prior to surgery
• Surveillance ECG was done on POD1

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Back to the Patients

• ST elevation MI
• Preserved ejection fraction
• Treated medically, dismissed from the hospital
  POD 15
• Died 5 months later from complications of bladder
  cancer

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• Older patients are at increased risk for a host
  of complications and it is probably easier to
  precipitate these complications than to prevent
  them. This precarious state is a function of
  decreased functional reserve, variable response
  to stress, and the number of comorbidities.
• DJ Cook and GA Rooke, 2003, Anesth Analg.

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Case 1

• A 92 yo woman, in a nursing home because of
  advancing dementia, falls and fractures her hip
  while making her bed!
• Past history includes dementia, hypertension,
  atrial fibrillation, moderate to severe aortic
  and mitral insufficiency, pulmonary hypertension
  and congestive heart failure (LVEF40).

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Case 1

• Can walk a short distance, but does complain of
  dyspnea
• Meds Toprol XL, Lisinopril, Donepezil

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Case 1

• Exam
• Awake and alert, not oriented to time or place
• Hard of hearing
• Pulse 80, irregularly irregular
• Holosystolic murmur at the apex, early diastolic
  murmur, lungs with basilar crackles
• No edema

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Case 1

• Data
• EKG A. fib with controlled ventricular response
• Sodium 128, creatinine 1.6, BUN 52
• UA gt100 WBCs with bacteria present

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• You are the medical consultant. What would you
  do?
• Tell the patient and her family that the risk of
  surgery is too high, and recommend hospice
• Send the patient to the ICU for invasive
  monitoring, and allow her to go to surgery
• Get a cardiology consult and let them decide
• Treat the UTI, start to correct the sodium, then
  send the patient to the OR when the Nagt 135

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Weighing the risks and benefits

• Benefits
• The mortality of an unrepaired hip fracture is
  extremely high- as much as 90 in the first 3
  months
• Surgical repair will relieve pain and improve her
  overall functional status

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Weighing the risks and benefits

• Risks
• Known heart disease, with at least moderate
  valvular disease, CHF, and pulmonary hypertension
  implies little cardiac reserve to tolerate the
  stress of surgery
• Her dementia makes obtaining informed consent
  from the patient difficult or impossible

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Weighing the risks and benefits

• Her dementia puts her at increased risk of
  postoperative delirium
• The presence of hyponatremia puts her at
  increased risk of postoperative delirium
• Elevated creatinine means that her renal reserve
  is limited and is also an additional risk factor
  for perioperative cardiac complications
• She already has a urinary tract infection

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Risks and Benefits

• Known heart disease
• Dementia
• Hyponatremia
• Elevated creatinine
• Urinary tract infection

• The mortality of an unrepaired hip fracture is
  extremely high- as much as 90 in the first 3
  months
• Surgical repair will relieve pain and improve her
  overall functional status

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Case 2

• An 89 yo woman who is being evaluated for total
  hip arthroplasty
• Hip fracture 9 months ago, ongoing severe hip
  pain, which has limited her ability to function
• Had NSTEMI after her hip fracture
• LVEF40 with RWMAs

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Case 2

• Postoperatively
• Acute on chronic renal insufficiency
• Delirium, which gradually cleared
• Now
• Lives alone with support from her family
• Does most of her own ADLs, but not iADLs
• Mild cognitive dysfunction
• Urinary incontinence

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Case 2

• Exam
• Heart rate 90, some PVCs
• Lungs clear
• Heart S3 gallop, no murmurs
• No edema
• Mild cognitive dysfunction

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Case 2

• Data
• Hgb 13.6, MCV 100.1
• K 5.0, creatinine 2.1
• NT-proBNP 2926 (nllt263)
• Dobutamine Stress Echo positive for myocardial
  ischemia, which occurred at a heart rate of 110

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• You are the medical consultant. What do you
  recommend?
• Start beta blockers and titrate to heart rate
  55-65 before surgery
• This is an elective procedure and should not be
  done because of the cardiac risk
• Refer the patient for coronary angiography before
  surgery
• Defer the decision until the patient has been
  seen by cardiology, nephrology and neurology

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Weighing the risks and benefits

• Benefits
• Relieve pain
• Improve function, which has been compromised due
  to pain
• Maintain independence
• Improve quality of life

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Weighing the risks and benefits

• Risks
• Coronary artery disease with abnormal DSE
• Renal insufficiency increases the risk of
  perioperative cardiac event
• Renal insufficiency, with creatinine clearance of
  about 14 ml/min increases the risk of drug
  toxicity

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Weighing the risks and benefits

• Previous postoperative delirium and mild
  cognitive decline increase the risk of
  postoperative delirium
• MCV of 100.1 raises the question of malnutrition,
  which is associated with increased perioperative
  mortality

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Risks and Benefits

• Benefits
• Relieve pain
• Improve function, which has been compromised due
  to pain
• Maintain independence
• Improve quality of life

• Risks
• Known CAD
• Renal insufficiency
• Cognitive dysfunction and delirium risk
• Malnutrition
• CHF?

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Case 3

• A 98 year old woman falls in her nursing home
  while ambulating with her walker.
• Right humerus and right hip fracture

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Case 3

• Past history
• CHF with 2/4 diastolic dysfunction
• Severe aortic stenosis (not felt to be a surgical
  candidate)
• Moderate dementia
• Chronic renal insufficiency
• Anemia (refused workup)
• Atrial fibrillation, heart rate drops to 20-30
  with beta blocker

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Case 3

• Medications
• Lisinopril
• Lasix
• Albuterol inhaler (no documented COPD)
• Celexa

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Case 3

• ROS (per family)
• No dyspnea
• Ambulates with walker
• No syncope

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Case 3

• Exam
• P 61 irregular, BP 130/80
• 3/6 late peaking systolic murmur
• Lungs clear
• No edema

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Case 3

• Labs
• Hgb 9.2 gm/dL, MCV 106.7, WBC 11.6, Plt 213, INR
  1.0
• Na 138, K 4.2, Cl 102, HCO3 28, BUN 35, Cr 1.7,
  Glucose 148
• EKG Sinus rhythm, prolonged QT, LAFB, ST-T
  abnormalities

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• You are the medical consultant. What do you
  recommend?
• The surgery is too high risk and the patient
  should be referred to hospice
• She should be started on beta blockers prior to
  surgery
• Her anemia should be corrected and she should be
  monitored in the ICU postoperatively
• She should be evaluated by cardiology to see if
  her valve can be repaired prior to surgery

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Weighing the Risks and Benefits

• Benefits
• She is having considerable pain and surgery would
  relieve that pain
• She does not want to be non-ambulatory for a
  prolonged period of time
• High mortality if hip fracture not repaired

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Weighing the Risks and Benefits

• Risks
• Critical aortic stenosis, will not tolerate
  hypotension or atrial fibrillation
• Cannot be given beta blockers
• High risk of postoperative delirium
• Surgery will carry a high mortality

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Risks and benefits

• Benefits
• Pain relief
• Ambulation
• Mortality from un-repaired hip fracture

• Risks
• Critical aortic stenosis
• Dementia- delirium risk
• High surgical mortality

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Principles of perioperative geriatric care

• Functional assessment
• Prevention of predictable disasters
• Management of complexity
• Seeking cumulative small gains in function
• Aggressive rehabilitation

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Principles of preoperative geriatric care

• Interdisciplinary team care
• Attention to social support status
• Guarding autonomy in end-of-life decision making
• Understanding the effects of dementia in the
  clinical setting

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Decision-making

• Pitfalls
• Underestimate of predicted remaining lifespan
• Failure to fully consider consequences of not
  doing the surgery

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Decision-making

• Goals of surgical therapy
• Maintain quality of life
• Improve or maintain functional status and
  independence
• Relieve pain

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Some other issues

• Elective vs emergency surgery
• Emergency operations are a significant source of
  morbidity and mortality in older patients
• Older patients require emergency operations more
  frequently than younger patients

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Some other issues

• Morbidity rates 30- 68 for emergency operations
  in older patients
• General surgical procedures in patients over 90
  all deaths after emergency surgery

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Some other issues

• Many elderly patients present for emergency
  surgery for known conditions which could have
  been treated with elective surgery

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In the end

• Elderly patients often benefit from surgical
  therapy
• Benefits include
• Enhanced patient function and independence
• Improved quality of life
• Relief of pain and suffering

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In the end

• Elderly patients are at increased risk from
  surgical procedures
• Age associated decline in organ system function
• Alterations in pharmacokinetics
• Decreased tolerance of stress
• Increasing presence of comorbidities

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In the end

• Medical team caring for these patients is
  responsible for
• Thorough preoperative assessment
• Identification of risk factors
• Optimization of medical conditions whenever
  possible

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In the end

• Postoperatively, the medical team must
• Correct metabolic problems quickly
• Monitor drugs to prevent adverse effects

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In the end

• Provide for adequate nutrition
• Be aware of signs of infection
• Encourage mobility and ambulation
• Provide adequate psychosocial support for
  patients and families

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In the end

• Comprehensive, multidisciplinary approach is
  improving surgical outcomes and improving
  morbidity and mortality in elderly patients

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Follow-up Case 1

• 92 yo woman with dementia, heart disease, hip
  fracture
• Well ß-blocked, no obvious heart failure
• Seen by cardiology
• Son (POA) gave informed consent, understood risks
  and benefits
• Went to ICU postoperatively x 24 hours
• No postoperative delirium
• Returned to NH POD 6

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Case 1

• You are the medical consultant. What would you
  do?
• Tell the patient and her family that the risk of
  surgery is too high, and recommend hospice
• Send the patient to the ICU for invasive
  monitoring, and allow her to go to surgery
• Get a cardiology consult and let them decide
• Treat the UTI, start to correct the sodium, then
  send the patient to the OR when the Nagt 135

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Follow-up Case 2

• 89 yo woman with CAD, positive DSE
• Low risk positive stress test
• ?-blockers started, heart rate controlled in 60s
• Underwent total hip replacement without problems,
  dismissed POD 5

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Case 2

• You are the medical consultant. What do you
  recommend?
• Start beta blockers and titrate to heart rate
  55-65 before surgery
• This is an elective procedure and should not be
  done because of the cardiac risk
• Refer the patient for coronary angiography before
  surgery
• Defer the decision until the patient has been
  seen by cardiology, nephrology and neurology

102
Follow-up Case 3

• 98 year old woman, hip fracture, aortic stenosis,
  renal insufficiency, dementia
• Seen by cardiology, no beta blocker, recommended
  keeping intravascular volume high
• Patient, family agree to proceed despite risks
• Surgery tolerated well, to ICU postoperatively
  for 24 hours

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Case 3

• You are the medical consultant. What do you
  recommend?
• The surgery is too high risk and the patient
  should be seen by hospice
• She should be started on beta blockers prior to
  surgery
• Her anemia should be corrected and she should be
  monitored in the ICU postoperatively
• She should be evaluated by cardiology to see if
  her valve can be repaired prior to surgery

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• We must be very careful not to protect our
  patients from perceived surgical risk and deny
  them the benefits of a carefully planned surgical
  procedure

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Case

• 68 year old female scheduled for an elective open
  cholecystectomy tomorrow, AM surgery
• Past history HTN, depression
• Meds Lisinopril 40 mg po AM, Sertraline 50mg po
  q HS.

107
Case

• Labs Creatinine 1.4, Na and K normal
• ECG normal
• Exam unremarkable, although she is very anxious
• Vitals BP 165/98, P 72

108

• You are the medical consultant. What do you
  recommend?
• Cancel the surgery until her blood pressure is lt
  140/85
• Start HCTZ, send to surgery tomorrow
• Continue her current medication, send to surgery
  tomorrow
• Start beta blockers, send to surgery tomorrow

109
Chronic hypertension

• Is chronic hypertension really a risk factor for
  perioperative complication?
• Is elevated BP prior to surgery a risk?
• What evidence supports delaying elective surgery
  in the patient with poorly controlled
  hypertension?
• How much BP control is needed and for how long
  preop?

110
Prys-Roberts et al. Studies of anaesthesia in
relation to hypertension. Br J Anaesth 1971

• 34 patients elective anesthesia surgery
• 15 normotensive
• 19 hypertensive (treated and untreated)
• Mean BP similar in both groups
• Untreated had greater decrease in BP at induction
• Untreated had more myocardial ischemia
• No adverse events in either group
• Implication Defer surgery to treat hypertension

111
Meta analysis of 30 studies No evidence that
preoperative hypertension directly affects
perioperative outcome
112
No perioperative risk Stage I BP (140-159 /
90-99) Stage II BP (160-179 / 100-109) Control
BP Preop Stage III BP (gt180 / gt110)
113
No perioperative risk Stage I BP (140-159 /
90-99 Stage II BP (160-179 / 100-109) Control
BP Preop Stage III BP (gt180 / gt110)
NO Supportive evidence
114
No discussion of perioperative hypertension
JNC VI 1997
115
JNC VII December 2003
116
JNC VII
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118
ACC / AHA 2007 Preoperative Evaluation Guideline
ACC / AHA 2007 Guideline
119
ACC / AHA 2007 Preoperative Evaluation Guideline
(ACC / AHA 2007 Guideline)
ACC / AHA 2007 Guideline
ACC / AHA 2007 Guideline
120
BP 165/98

• You are the medical consultant. What do you
  recommend?
• Cancel the surgery until her blood pressure is lt
  140/85
• Start HCTZ, send to surgery tomorrow
• Continue her current medication, send to surgery
  tomorrow
• Start beta blockers, send to surgery tomorrow

121
Major issues of chronic hypertension

• Too aggressive control of BP a problem
• Increased perioperative hemodynamic lability
• More comorbidities
• CAD
• CHF
• CRF
• Medication management
• perioperative continuation of medications

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Case

• A 65 year old man with known moderate hemophilia
  A presents with an infected right total knee
  arthroplasty
• The surgical plan is for initial removal of the
  infected prosthesis, with placement of an
  antibiotic impregnated spacer, IV antibiotics,
  and ultimately placement of a new prosthesis

124
Case

• The patient has required bilateral total knee
  arthroplasties, due to damage from multiple
  hemarthroses
• He also has a history of type 2 DM, CAD and
  hypertension

125
Case

• You are the medical consultant. The surgeon asks
  about perioperative management of his bleeding
  problems. What do you recommend?

126

• Treatment should be based on his clinical course
• He should receive Factor 8 concentrate to
  maintain his level at 100 perioperatively
• He should receive both Factor 8 concentrate and
  LMWH perioperatively
• He should receive Factor 8 concentrate to
  maintain his level at 75 and no DVT prophylaxis

127
Classification of Hemophilia
128
Antithrombotic Prophylaxis In Persons With
Hemophilia Undergoing Orthopedic Surgery
129
Prophylaxis Schedule For Indications Other Than
Cardiovascular Diseases In Elderly Persons With
Severe Hemophilia
Major surgery, especially orthopedic
Mancucci PM, Blood 2009
130

• Treatment should be based on his clinical course
• He should receive Factor 8 concentrate to
  maintain his level at 100 perioperatively
• He should receive both Factor 8 concentrate
  (Level 100) and LMWH perioperatively
• He should receive Factor 8 concentrate to
  maintain his level at 75 and no DVT prophylaxis

131
References- Stents

• Shilling AM, Duriex ME. Pharmacologic Modulation
  of operative Risk in Patients Who Have Cardiac
  Disease. Anesthesiology Clin N Am 2006
  24365-379.
• Newsome LT, Weller RS et al. Coronary Artery
  Stents II. Perioperative Considerations and
  Management. Anesth Analg 2008 107570-90.

132
References- Stents

• Chassot PG, Delabays A, Spahn DR. Perioperative
  antiplatelet therapy the case for continuing
  therapy in patients at risk of myocardial
  infarction. Br J Anesth 200799 316-28.
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