Surgery and Stents

March 1, 2009

Stents are the ingenious hi-tech devices implanted in blocked coronary arteries by cardiologists, our high priests of interventional medicine. In the last 3-5 years we’ve learned unfortunately that coronary stents are not the panacea once hoped for. A major problem with stents is that they tend to become blocked off themselves unless anti-platelet medication, such as Plavix, is taken, for months or even years.

One of the main purposes of pre-surgery evaluation is to find out whether a patient has coronary artery disease and is therefore at risk for having a heart attack or other heart complication during or after surgery. We used to assume that¬† offering these patients stents (‘re-vascularisation’) would protect them from these kinds of heart problems.

In fact, studies have shown that patients who’ve been very recently ‘stented’ often have worse outcomes. For major surgery, anti-platelet drugs are usually stopped, in order to prevent bleeding. Unfortunately stopping these medications, combined with the complex effects of surgery on blood clotting, leads to a much greater chance that the stent, and therefore the artery, will block off, thereby causing the cardiac complication we were trying at all costs to avoid.

Guidelines from the American College of Cardiology, the American Heart Association, and the American Society of Anesthesiologists, now recommend postponing major elective surgery in which there is significant risk of bleeding, in patients with new coronary stents.

If you have a bare-metal stent the minimum recommended wait is 4-6 weeks. If you have a drug-eluting stent the wait is 12 months after implantation.

Decision-making (e.g. when to have the surgery, when to stop or continue medications) can be quite complex in this situation. Very often, surgery cannot be postponed, and the risks have to be carefully weighed to make a good choice.

What You Should Do

Make sure your anesthesiologist and your surgeon know that you have a coronary stent, when it was put in, what type it is, and what medications you are taking.

Assessing risks and benefits, to guide decision-making about going forward (or postponing) surgery, and about stopping or continuing anti-platelet drugs will involve a discussion between your surgeon, your anesthesiologist, and your cardiologist. With your input of course.

Reference

Practice Alert for the Perioperative Management of Patients with Coronary Artery Stents: A Report by the American Society of Anesthesiologists Committee on Standards and Practice Parameters. Anesthesiology: January 2009 – Volume 110 – Issue 1 – pp 22-23. Link.


The Surgical Checklist Saves Lives

January 18, 2009

The New England Journal of Medicine published a special study reporting the success of the World Health Organization’s Surgical Safety Checklist in reducing lives and preventing major complications after non-heart surgery. Eight hospitals in developed (US, Canada, New Zealand) and developing (India, Jordan, Kenya, Phillipines, Tanzania) countries were involved, and the positive results were seen in both settings.

The checklist involves steps at “sign-in” (e.g. verifying the patient’s identity, and the site of operation), immediately before cutting the skin (e.g. antibiotics given, X-rays are in the room), and just before the patients leaves the operating room (e.g. needle, sponge and instrument counts are complete).

The overall death rate decreased from 1.5 to 0.8%, and complications went down from 11 to 7%. This is really remarkable. If these results were achieved by a drug or a new surgical technique you can bet it would be patented immediately and be worth billions.

The explanation for such amazing results?¬† Use of a checklist initiates a change in mindset, culture, call it what you will, that facilitates open communication. The checklist also says that the surgeon is fallible, the anesthesiologist is fallible, the nurse is fallible, but that collectively we can help each other avoid mistakes by routinely and systematically discussing what needs to be done, and using a written list to help us all remember some key steps. Studies of human performance show that we make mistakes on routine tasks at least once or twice in every 100 times. That simply isn’t good enough in healthcare, as in other high risk human endeavors.

The fact that such checklists aren’t routinely used in the majority of the world’s hospitals is fairly shocking to many. And despite this result, it’ll no doubt take some time before such basic safety measures are embraced by ALL hospitals. Why?

As Rene Amalberti, a safety and performance expert has found, in studies across industries, there is always a tension between reliability/safety one the one hand, and productivity on the other. In healthcare we routinely stray into territory that increases risks to patients (and ourselves), not because we are cowboys, or cavalier, but because there are very real constraints on resources. We probably could do a perfect job, within the limits of medical science, if we all did one operation a day, but it would be very expensive, and all our other patients would miss out on their needed care.

It’s hard to argue against the checklist however because it’s simple to do, doesn’t cost money, and can be complete in one or two minutes.

My Advice

If you’re a patient, look for evidence that your chosen hospital is implementing checklists, across the board. Or choose another hospital.