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R Pulmonary Angiogram w/ FB removal

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by

Marcel Graf

on 10 September 2014

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Transcript of R Pulmonary Angiogram w/ FB removal

Stats:
27 F; 162 cm; 63 kg; ASA 2; (lived on a shrimp boat???)
NPO:
>12 hrs
SocHx:
denies
Allergies:
Sulfa (?), Morphine (?)
PMH:
Ulcerative Colitis, Factor V Leiden & AT III deficiency; Ovarian Rupture, DVT/PE s/p permanent IVC filter
PSH:
Colectomy, Ilieostomy, Ex-Lap, SBO
Meds:
Coumadin (dc ~2 days); Lovenox
Labs:
PT--18.2 PTT--33.6 INR--1.53 D-Dimer--0.21

Consider the limitations/hazards of working at a remote location
Iodine/Shellfish allergy
Moving C-arm (lines)
Communication is key
Quirky surgeon

Pulmonary Angiography w/ FB removal
---
Factor V Leiden & Inherited AT III deficiency: It's a family affair!

Objectives
Pre-Introduction: Review Pathophysiology
Meet the Patient
Meet IR 02 and the Surgeon
Our Anesthetic Plan
The Case
End Notes*
Factor V Leiden & AT III deficiency
Factor V Leiden: an autosomal co-dominant disorder resulting in production of Protein C-resistant factor V.
Inherited AT III deficiency: an autosomal dominant disorder in which Anti-Thrombin III production is diminished.
Factor V Leiden and AT III deficiency in combination is a highly thrombophilic pathology, greatly increasing the risk of VTE and/or PE.
Other risk factors for VTE: Immobilization, BMI > 30, CV Dz, Cancer/Chemotherapy, Pregnancy, Oral Contraceptives, Trauma, etc.

The Coagulation Cascade
Coagulation cascade in the big picture...
The Patient
The Case
I cried at the end of 'The Notebook'
Disclosures:
Coagulation cascade re: anesthesia
Mentor: Mehta, MD
Mentor: Trzaska AA-C

Formulating a Plan
Worst
: Bleed in pulmonary vessel-or-Hypercoagulation Crisis (HIT, worsen PE)
Best
: FB is quickly retrieved with minimal blood loss.
Plan:
GA with Standard ASA monitors, 2nd IV, no A-line, continual ACT testing and Heparin PRN. Generous use of muscle relaxant and/or greater depth of anesthesia.

IR 02 and the Surgeon
Indications for IVC filter
Presence of DVT or PE with any of the following conditions:
-Contraindication to anticoagulation
-Recurrent PE in spite of anticoagulation
-Anticoagulation-related complication
"She shouldn't be doing that!"
Permanent IVC Filter Use is Controversial
Studies find long-term (permanent) IVC filter ineffective PE prophylaxis, and increase the risk of DVT.
Bariatric study found IVC filters doubled the risk of DVT in pts with no prior history of DVT (0.42% vs 0.21%).
2010: FDA recommends IVC filter for short-term use only. From FDA's announcement: "Since 2005, the FDA has received 921 device adverse event reports involving IVC filters, of which 328 involved device migration, 146 involved embolizations (detachment of device components), 70 involved perforation of the IVC, and 56 involved filter fracture."
End Notes
References
No patient update.
Changes in our management?
Consider the financial cost to the patient
Myall, Peter. “Prophylactic IVC Filter Insertion: More risks than benefits.” Bariatric News (2010)http://www.bariatricnews.net/?q=news/11351/prophylatic-ivc-filter-insertion-%E2%80%9Cmore-risks-benefits%E2%80%9D

Sorensen, B., & Fries , D. (2012). Emerging treatment strategies for trauma-induced coagulopathy . British Journal of Surgery , 99(1), 40-50.

Stoelting, Robert K., and Ronald D. Miller. Basics of Anesthesia. 5th ed. Philadelphia: Churchill Livingstone, 2007.

From FDA.gov. The Department of Human Health and Services (2010) http://www.fda.gov/Safety/MedWatch/SafetyInformation/SafetyAlertsforHumanMedicalProducts/ucm221707.htm

Telly M., Bhatt, D., (2007) Clinical Aspects of Platelet Inhibitors and Thrombus Formation. Circulation Research, 100, 1261-1275

Barash, Paul G., Bruce F. Cullen, and Robert K. Stoelting. Clinical Anesthesia. 7th ed. Philadelphia: Lippincott Williams & Wilkins, 2009.

Duke, James. Anesthesia Secrets. 4th ed. Philadelphia, PA: Mosby Elsevier, 2011.
Pre Op Evaluation
1) NPO status
2)
Full transcript