Thoracentesis on ASA/Plavix

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not-on-fire

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What are other people doing? Insist on holding both? Go ahead and go for it? (Non-toxic patients without urgent indication for thoracentesis.)
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If it's really non-urgent and the patient is outside a one month window of stent, DE or BM, I'd probably have them hold for like 5-7 days. I've done thoracentesis on patients on both agents before without any problem. My patient population to this point seems to almost always be on ASA and very likely to be on the plavix as well.
 
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jdh71 said:
If it's really non-urgent and the patient is outside a one month window of stent, DE or BM, I'd probably have them hold for like 5-7 days.
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Current AHA and FDA recommendation for DES is a minimum of 12 months continuous dual anti-platelet therapy. Stopping a fresh DES patient's clopidogrel before that time is asking for a fatal MI. We really don't know what the true safe minimum treatment duration is.

You could check a Verify Now (P2Y12) test to get an idea of % platelet inhibition. There's a significant % of patients who don't have a high inhibition. TEG does not reflect clopidogrel-platelet inhibition.

I would do the thoracentesis on both drugs, if the procedure really needed to be done. I'd use lidocaine with epi to get some vasoconstriction and the most experienced operator should do the procedure. If there's bleeding, you'll get to do the chest tube.
 
proman said:
Current AHA and FDA recommendation for DES is a minimum of 12 months continuous dual anti-platelet therapy. Stopping a fresh DES patient's clopidogrel before that time is asking for a fatal MI. We really don't know what the true safe minimum treatment duration is.

You could check a Verify Now (P2Y12) test to get an idea of % platelet inhibition. There's a significant % of patients who don't have a high inhibition. TEG does not reflect clopidogrel-platelet inhibition.

I would do the thoracentesis on both drugs, if the procedure really needed to be done. I'd use lidocaine with epi to get some vasoconstriction and the most experienced operator should do the procedure. If there's bleeding, you'll get to do the chest tube.
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Dude. I know how long its recommended to give a stenter plavix. These are my patients. The data for 12 months is weak when you look at it in my opinion, and recommendation largely an overreation (made the makers of plavix very happy). The one month use has much better evidence for both the DE and BM.

The CT surgeons and cardiologists routinely stop the plavix for procedures for up to a week after one month for CABG when it's necessary after emergent PCI.

It's not "asking for an acute MI". It's a low probability possibility. Risks versus benefits. Ironically the same population that could MI or stroke at any time regardless of having plavix or not. These decisions are part of why we get paid the big bucks.
 
It's hard to draw the line of "need," though.
Asymptomatic but moderate effusion, or asymptomatic asymmetric bilateral effusion, or (my favorite) - asymptomatic, but I am asked to consult specifically for the thoracentesis and then the patient will be discharged.
Or all the above but only mildly symptomatic.
The IR guys don't seem to mind the anti-platelet agents.
Am I being ridiculous in wanting them to be held (barring fresh-ish stents)?
I couldn't find solid data, so I really appreciate people's experiences.
 
jdh71 said:
Dude. I know how long its recommended to give a stenter plavix. These are my patients. The data for 12 months is weak when you look at it in my opinion, and recommendation largely an overreation (made the makers of plavix very happy). The one month use has much better evidence for both the DE and BM.
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I routinely deal with patients whose internists stop dual-antiplatelet therapy earlier than recommended for elective procedures. Guess what? We don't do the case. It's an invitation for 1) a bad outcome and 2) lawsuit that is indefensible. At least the cardiologists have come on board. After 4 weeks a BMS barely has a neo-endothelium, a DES certainly is not protected. While the EXCELLENT trial supports a shorter 6 months of treatment, it's not prospective and underpowered for the hard endpoints (the composite showed non-inferiority).

jdh71 said:
The CT surgeons and cardiologists routinely stop the plavix for procedures for up to a week after one month for CABG when it's necessary after emergent PCI.
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Completely different patient population. Now you're talking about non-elective (urgent at best) procedures. My cardiac surgeons bridge with heparin, so no one waits a month without clopidogrel. It's usually a max of 3 days, hoping for some good platelets. These patients usually get multiple doses of platelets which isn't an issue because their DES just got bypassed.

jdh71 said:
It's not "asking for an acute MI". It's a low probability possibility. Risks versus benefits. Ironically the same population that could MI or stroke at any time regardless of having plavix or not. These decisions are part of why we get paid the big bucks.
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The evidence is as strong as Phase IV data can be. The risk is small (<1%) but the risk of MI or death from in stent thrombosis is 30%. That is unacceptable for an elective procedure. We're paid the big bucks to do the right thing for patients. You're going to find little support for 1 month dual therapy after a DES. It's just not worth the risk, and we can do many procedures on dual therapy. Anyway, we don't even know why this patient is on clodpidogrel, so this may be all a moot point.

I'm curious, how long post MI do you think we should wait to do an elective operation?
 
Here's some evidence, BTW when was the last time you saw a hazard ratio of 89 for anything?:

JAMA 2005;293:2126
Incidence, Predictors, and Outcome of Thrombosis After Successful Implantation of Drug-Eluting Stents
Results At 9-month follow-up, 29 patients (1.3%) had stent thrombosis (9 [0.8%] with sirolimus and 20 [1.7%] with paclitaxel; P = .09). Fourteen patients had subacute thrombosis (0.6%) and 15 patients had late thrombosis (0.7%). Among these 29 patients, 13 died (case fatality rate, 45%). Independent predictors of stent thrombosis were premature antiplatelet therapy discontinuation (hazard ratio
, 89.78; 95% CI, 29.90-269.60; P<.001),
renal failure (HR, 6.49; 95% CI, 2.60-16.15; P<.001), bifurcation lesions (HR, 6.42; 95% CI, 2.93-14.07; P<.001), diabetes (HR, 3.71; 95% CI, 1.74-7.89; P = .001), and a lower ejection fraction (HR, 1.09; 95% CI, 1.05-1.36; P<.001 for each 10% decrease).

Am J Cardiology 2006;98:352
Frequency of and Risk Factors for Stent Thrombosis After Drug-Eluting Stent Implantation During Long-Term Follow-Up

The incidence of stent thrombosis was 3.3% (4 of 121 patients) in patients with complete interruption of antiplatelet therapy (vs 0.6% in those without, p = 0.004) and 7.8% (5 of 64 patients) with premature interruption of aspirin or clopidogrel, or both (vs 0.5% in those without, p <0.001). Independent predictors of stent thrombosis were premature antiplatelet therapy interruption, primary stenting in acute myocardial infarction, and total stent length.

And the current recommendations:
King SB III, Smith SC Jr, Hirshfeld JW Jr, et al. 2007 Focused Update of the ACC/ AHA/SCAI 2005 Guideline Update for Per- cutaneous Coronary Intervention: a report of the American College of Cardiology/ American Heart Association Task Force on Practice Guidelines. Circulation 2008;117: 261-95.

Clinical Trial :NCT00661206 is looking at 6 months vs 12 months. That's probably the shortest duration anyone will consider.
 
proman said:
I routinely deal with patients whose internists stop dual-antiplatelet therapy earlier than recommended for elective procedures. Guess what? We don't do the case. It's an invitation for 1) a bad outcome and 2) lawsuit that is indefensible. At least the cardiologists have come on board. After 4 weeks a BMS barely has a neo-endothelium, a DES certainly is not protected. While the EXCELLENT trial supports a shorter 6 months of treatment, it's not prospective and underpowered for the hard endpoints (the composite showed non-inferiority).

The evidence is as strong as Phase IV data can be. The risk is small (<1%) but the risk of MI or death from in stent thrombosis is 30%. That is unacceptable for an elective procedure. We're paid the big bucks to do the right thing for patients. You're going to find little support for 1 month dual therapy after a DES. It's just not worth the risk, and we can do many procedures on dual therapy. Anyway, we don't even know why this patient is on clodpidogrel, so this may be all a moot point.

I'm curious, how long post MI do you think we should wait to do an elective operation?
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The problem is you're trying to extrapolate people that completely stopped taking their plavix entirely and then saw events. As well as this, I think bringing up the going to the operating room vs a quick out-patient clinic procedure is definitely trying to compare apples to oranges. I'm not suggesting only doing one month of dual therapy after a DES. Your point is that holding the plavix for any period of time is wrong because it carries a small potential risk that you don't want to deal with. I don't disagree with that point necessarily, which is why you talk with the patient about risks versus benefits. Sometimes doing "what is best for the patient" is taking a very small risk, if the patient prefers being able to walk to bathroom or going into the kitchen to make a sammich without sucking on 6 liters of home O2 and getting dyspneic. Most of my patients will take that risk just about every day of the week. Sometimes I think you gas passers forget about some of the other issues that occur outside of your OR. I'd prefer that quick and simple procedure carry as few complications as possible, and then the patient goes right back on plavix. I'm not suggesting not using plavix long term.

How "elective" an operation? And what other things are going on with the patient? Is this a guy without an other issues except for MI? Why'd he MI? What was the cause? What kind of MI? What's his current function? What was it before? Current meds?Etc. Etc. There's all kind of questions to consider. Anywhere from 2-3 month to NEVER . . .
 
We are talking about a thoraCENTESIS right? Sticking a 14G in over the rib and pulling out fluid. I would not even consider stopping plavix/asa in this situation.
 
dbiddy808 said:
We are talking about a thoraCENTESIS right? Sticking a 14G in over the rib and pulling out fluid. I would not even consider stopping plavix/asa in this situation.
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sad thing is one my attendings wouldn't let me do a paracentesis on a pt on plavis that I thought needed SBP r/o.
 
Hi. I'm a surgeon... here my perspective because when I'm on my thoracic rotations, we get called about patients like this sometimes.

If a patient is on asa/plavix and recently had a DES, and really needs a thoracentesis, then, it's pretty silly to stop taking those drugs for such a minimally invasive procedure like that.

HOWEVER, that's not to say that the procedure is not without risk. I had a patient exsanguinate from a thoracentesis pulmonology did who wasn't on any asa/plavix. Was a sick patient in the ICU, and granted, it's a VERY VERY RARE phenomenon to have someone bleed significantly after a little needle... but it's possible And when you see it once, you learn to respect it.

Same with central lines. Everyone feels SOO comfortable with their femoral lines....until you nab the artery a little too high up and they try and bleed to death into their retroperitoneum (also happened to me).

The point is, if someone needs a procedure.. do it... keep em on the asa/plavix if necessary, but it's not the case where the intern or medical student should be learning on.
 
for urgent
max med manage 1st
stent bms: 1mo
stent DE:1yr..yup. at least a MINUMUM 3 mo. wouldnt touch with 10foot pole

No stent: Type II MI: 2week for urgent. Type I MI: 1mo (need plavix 1 mo).
this is incredibly case dependent

Elective: BEST to wait a minimum of least 6 weeks. Goal to wait 3mo.

Dont be an idiot, get cards involved if urgent.

i do thora on asa and plavix. if plavix may use US. I dont do if on full dose lovenox or hep ggt.

there is NO INR cutoff for para. i wouldnt flinch on asa/plavix
 
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Hernandez said:
I completely agree.
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Also agree. Rads wont do thoras here with INR >1.5 but I have done several in the 2-2.4 range for Afib/warfarin patients. Plavix/ASA no hesitation at all. But to add to your US point, I do every thora and para with US regardless of easy they should be without it in patients with huge effusions. Just dont see the need to do it blind. And I dont stick any bellys on coumadin/pradaxa/xarelto. period.
 
I did do one thora on pt with full dose lovenox. malignant effusion with tachypnea and dyspnea sats 92% 5L NC. guy was starting to work pretty good but no AMS. 1.5L off, pt much more comfortable. Lateral approach with pt supine. US GUIDED. no complication.
 
VentdependenT said:
I did do one thora on pt with full dose lovenox. malignant effusion with tachypnea and dyspnea sats 92% 5L NC. guy was starting to work pretty good but no AMS. 1.5L off, pt much more comfortable. Lateral approach with pt supine. US GUIDED. no complication.
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yeah you hit the nail on the head, the indication. Most paras and thoras I get asked to do are diagnostic, not theraputic and most certainly not urgent. In your situation, I would have tapped with the 'you might bleed from this but it will decrease your chances of me needing to shove a tube down your throat."
 
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