would you expect to get sued?

[deleted59964]

hi all, i'm a med student - & have an honest question about surgical practice - do you think this urologist did anything wrong???

The Situation
a family member had a TURP last week, all went well from a surgical viewpoint, but just as he was about to be discharged he had a VT arrest, needing DCR, 15 min CPR, spent 3 days in ICU on a balloon pump, inotropes, and vent (cooled, paralysed)... Some good news, woke up neurologically intact.

OK, some background

Family member is 62 yo male, with PHx of AMI 3.5 years ago which was treated with a drug eluting stent. Otherwise, healthy - (BMI 25, ex smoker stopped 10 years ago, on a statin and beta blocker, exercises regularly, able to cycle 40km, manual work).

Here's the dodgy bit

Seen by FP for BPH, large residual (1.2l) - sent to urologist for evaluation. Gets call from hospital (not sure who) saying come in Wed (4 days time) for your SURGERY and stop taking your aspirin (not on any other antiplatelet)
...ummm WHAT surgery

anyway being of that generation and an agreeable person, he does as he is told. "Surgery" involved catheter insertion and hourly measures of urine output post op (sorry dont know much about urology).

he is then told he needs a TURP, and that they can fit him in a few weeks later.

next day he is told he can have his TURP today, since he has been off his aspirin. goes ahead, has TURP.

At no stage was there a pre-op cardiology consultation.

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[sponch]

turp is a low risk procedure.

perioperative MI is a known complication of surgery.

given recent stent placement and high functional capacity ("able to bike 40km") there's little to suggest a high risk of cardiac complications.

furthermore, given how recently he got a stent, i'd bet that he's had a recent stress test/echo.

all these things are reviewed by the anesthesiologist in preop.

i don't know all the details of this case, obviously, but i'd think you'd have to look real hard to find any basis for a malpractice claim. surgery is not benign and complications can happen in the easiest, most basic cases.

hi all, i'm a med student - & have an honest question about surgical practice - do you think this urologist did anything wrong???

The Situation
a family member had a TURP last week, all went well from a surgical viewpoint, but just as he was about to be discharged he had a VT arrest, needing DCR, 15 min CPR, spent 3 days in ICU on a balloon pump, inotropes, and vent (cooled, paralysed)... Some good news, woke up neurologically intact.

OK, some background

Family member is 62 yo male, with PHx of AMI 3.5 years ago which was treated with a drug eluting stent. Otherwise, healthy - (BMI 25, ex smoker stopped 10 years ago, on a statin and beta blocker, exercises regularly, able to cycle 40km, manual work).

Here's the dodgy bit

Seen by FP for BPH, large residual (1.2l) - sent to urologist for evaluation. Gets call from hospital (not sure who) saying come in Wed (4 days time) for your SURGERY and stop taking your aspirin (not on any other antiplatelet)
...ummm WHAT surgery

anyway being of that generation and an agreeable person, he does as he is told. "Surgery" involved catheter insertion and hourly measures of urine output post op (sorry dont know much about urology).

he is then told he needs a TURP, and that they can fit him in a few weeks later.

next day he is told he can have his TURP today, since he has been off his aspirin. goes ahead, has TURP.

At no stage was there a pre-op cardiology consultation.

 

[deleted59964]

thanks for your input - is it common practice to cease aspirin in patients with drug eluting stents without a cardiologists review?

In retrospect I wish he'd seen a cardiologist first, there's some evidence that drug eluting stents block late more frequently than normal stents, especially when aspirin/clopidogrel are ceased. The cardiologists are telling us that he should now have cards input before any future elective surgery, and that they would probably suggest keeping the aspirin &/or clopidogrel going unless absolutely necessary. Knowing that's the cards opinion would you want the aspirin stopped?

please dont get me wrong here - I have no desire to blame anyone, and am perfectly aware that some times you just get a bad outcome.

 

[cytoskelement]

hmmm... so, they admitted the patient and did a turp the next day. well. the ASA would still have significant antiplatelet function given the half-life of platelets. so, its doubtful that DC'ing the ASA would have contributed to the problem.

 

[deleted59964]

yes, total time off aspirin was about 1 week

 

[nimbus]

Perioperative management of DES is evolving with new evidence emerging only within the last few years. The news has not spread to all surgical specialists.

Current recs appear to be:

1. dual antiplatelet therapy (plavix+ASA) for at LEAST 1 year. Could be longer depending on extent and positon of stents.

2. Single antiplatelet therapy for LIFE, including perioperative periods unless there is a high risk of uncontrollable life threatening hemorrhage.

3. No elective surgery X 1 year minimum.

the current recs could change to include bridging antiplatelet therapy with GP2b3a inhibitors.

http://www.apsf.org/resource_center/newsletter/2007/summer/05_cardiology_stents.htm

As the link states, risk of stent thrombosis is 29% when not appropriately managed. Mortality of stent thrombosis is 20-45%. this would yield an overall mortality of 5-15%. Not worth it to stop antiplatelet therapy in my opinion unless it is a big spine tumor or the like.

 

[johankriek]

turp is a low risk procedure.
.

no its not.. The population is usually high risk and the procedure in and of itself is not that lo risk. There are many many complications to turp. namely turp syndrome. fluid overload. etc etc. I would have gotten cardiology consultation

 

[Shalom77]

Actually it really depends on what the local standard of care is.

TURP is one of those procedures where there is reasonable evidence of increased blood loss if one continues ASA throughout surgery (one study found median blood loss 284 on ASA vs 144 off ASA) , although there is also a study that looked whether time of restarting ASA influenced bleeding complications that found that it makes no difference if one restarts it a day after surgery versus three weeks.

A survey of UK urologists published in 2006 found that 62% would stop ASA before performing a TURP and 40% would cancel planned TURP if ASA had not been stopped.

I think this is an area where guidelines and evidence is still evolving and even with a cardiology consult there's a good chance that the ASA would have been stopped. Stent placement in this case was 3.5years ago so we are not talking about the 1 year window. Active person biking 40km with regular manual work - would a pre-op stress test given more information - unlikely, etc.

There's a lot of uncertainty in medicine which is part of why they say - hindsight is 20-20.

 

[Shalom77]

In terms of knowing cards opinion - obviously that's their opinion after the complication - there's no knowing exactly what their opinion would have been before the complication unless you have a cardiologist who always recommends the same thing. In that case the opinion one would get in a case like this very likely depends on which cardiologist one asks.

After a complication like this - obviously you would follow cardiogy's advice.

 

[nimbus]

In terms of knowing cards opinion - obviously that's their opinion after the complication - there's no knowing exactly what their opinion would have been before the complication unless you have a cardiologist who always recommends the same thing. In that case the opinion one would get in a case like this very likely depends on which cardiologist one asks.

After a complication like this - obviously you would follow cardiogy's advice.

I have yet to see any of our cardiologists recommend discontinuation of all antiplatelet therapy for a patient with DES. Every recommendation I have seen in the last 2 years has been to continue at least aspirin.

 

[nimbus]

Actually it really depends on what the local standard of care is.

TURP is one of those procedures where there is reasonable evidence of increased blood loss if one continues ASA throughout surgery (one study found median blood loss 284 on ASA vs 144 off ASA) , although there is also a study that looked whether time of restarting ASA influenced bleeding complications that found that it makes no difference if one restarts it a day after surgery versus three weeks.





A survey of UK urologists published in 2006 found that 62% would stop ASA before performing a TURP and 40% would cancel planned TURP if ASA had not been stopped.

I think this is an area where guidelines and evidence is still evolving and even with a cardiology consult there's a good chance that the ASA would have been stopped. Stent placement in this case was 3.5years ago so we are not talking about the 1 year window. Active person biking 40km with regular manual work - would a pre-op stress test given more information - unlikely, etc.



There's a lot of uncertainty in medicine which is part of why they say - hindsight is 20-20.

284 ml vs 144 ml? Not clinically significant IMO.

Someone with high functional capacity with an open stent just has more to lose when the stent thromboses.

Consensus appears to be aggressive antiplatelet therapy even at the expense of increased bleeding risk.

 

[Shalom77]

I agree that the comparison of the median amount was not clinically significant. The 75% quartile was more clinically significant (379 vs. 660) However, I think the paper did not find any difference in amount of blood transfusions. Nonetheless their conclusions were that ASA should be stopped. Other studies did not find such a difference and concluded that ASA can be continued. However, in reviews on the whole whether to stop ASA or not, TURP was listed as a possible exception. Most procedures apparently have no increased bleeding risk with not stopping aspirin.

Whose "consensus" are you talking about.

Lawsuits are based on the local standard of care.

So for the original poster what matters is what is the standard of care in his area. I would argue that in terms of the literature standard of care is still evolving but certainly moving in the direction of not stopping ASA - since it appears that the thrombotic risks outweight the bleeding risks. But most articles qualify this in saying that there needs to be formal studies.

In any case, not stopping aspirin represents a change in practice for the majority of urologists and such changes in practice often take a while to "trickle down" to the masses of practicing physicians. It's very likely that a substantial proportion of urologists still stop ASA before TURP. If that is still a standard practice in the area where the urologist is practicing - which is certainly possible and I might argue likely - then one can't argue that it was malpractice. Just because the latest studies suggest that "ideal" practice is not to stop ASA doesn't make it the local standard of care.

 

[deleted59964]

Thanks, I appreciate the debate. I really hope that this case gets added to the body of evidence of the dangers of stopping aspirin in patients with drug elluting stents.

 

[former military]

I had a few disjointed comments to make

1) some might argue that a patient such as this should have gotten a green light laser turp on aspirin rather than a traditional turp. I won't turp people with artificial heart valves off anticoagulation. I do turp people with hx of DVTs and afib off anticoagulation but I document the risks, increased risks off anticoagulation, other options.

2) people have MIs on aspirin too

3) turp has morbidity, as does general anesthesia... many urologists won't even touch higher risk patients and just condemn them to intermittent self catheterization or indwelling foley catheter. there is no huge win in getting an older man voiding and a huge loss when the finger pointing starts when I guy has complications.

4) persons turp'd can bleed significantly when their anticoagulation is restarted early

5) my experience is cardiologists are really not too psyched to see these people preop. they figure the vast majority can be figured out by primary care and anesthesiology. if they have exercise intolerance, unstable angina, etc they will see them... but that is generally a red flag not to operate on them.

6) people have MIs and strokes after turps even with cardiology preop consults and even if they are completely healthy. surgery involves risk

 

[bobbyseal]

The problem is that cardiology has done too good of a job with heart disease. These people would have died out from a sudden heart attack in their 50's and 60's before stents, lipitor, etc. Now these guys are living into their 70's and getting big prostates that need to be resected. Unfortunately, they're limping by on an EF of 20%. But, they can't pee, and we urologists need to make it so they can.