65-year-old man for a revision of a PLIF
Background
- Lung Transplant patient – pulmonary Fibrosis
- IHD, CABG in 2010
- IDDM
- Chronic Back pain with radiculopathy.
Issues
- L5/S1 PLIF 3 months ago
- Ongoing disabling back pain since procedure, resistant to multiple therapies
- NSTEMI 2 weeks postoperatively while in rehab
- Required urgent angioplasty and stent to RCA
- 10 days post MI, had S1 screw revision due to persistent pain
- Procedure performed on DAPT
- Persistent pain, surgical revision required due to unstable construct
Discussion
Timing of Surgery
- Consulted with treating cardiologist, increased length of RCA stent and therefore a higher risk of in-stent thrombosis
- Patient on DAPT and Apixaban
- Cardiologist would prefer to wait 3 months post PCI and then perform surgery on Aspirin
- Surgery urgent due to unstable construct therefore decision made to proceed.
- Clopidogrel and apixaban ceased preoperatively
Postoperative Disposition; ICU vs Telemetry bed
- Telemetry usually provides single lead monitoring and there may not be adequate ST segment assessment in this situation
- ICU can provide ECG and haemodynamic monitoring, with the additional benefit of haemodynamic support if required
- Decision may be affected by bed availability
Postoperative Troponin measurement
- Patient should have postoperative troponin measurements for 48-72 hours as per Canadian guidelines
- Discussion centred around management of increased Troponin in this case. Noted that increase troponin may be caused by non-cardiac conditions that require urgent intervention (eg PE or sepsis)
- DAPT will be recommenced as soon as surgical team happy bleeding risk is reduced
- Vision study: noncardiac surgery, peak postoperative hsTnT during the first 3 days after surgery showed significant correlation with 30-day mortality.
- https://jamanetwork.com/journals/jama/fullarticle/2620089