Outpatient Surgery Magazine, providing current information on Surgical Services, Surgical Facility Administration, Outpatient Surgery News and Trends, OR Excellence and more.
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5 0 O U T P A T I E N T S U R G E R Y M A G A Z I N E O N L I N E | O C T O B E R 2 0 1 5 You're an anesthesiologist at a fast-paced, high-volume orthopedic surgery center. A nurse from pre-admission testing brings a patient chart for you to review. She tells you that a patient was just added onto the surgery schedule for tomorrow and that Dr. Smith, the orthopedic surgeon, needs to do this case before he flies out of town tomorrow after- noon for a conference. The patient is a 36-year-old Asian female scheduled for an open reduction and internal fixation of proximal humerus fracture. The patient is 5-foot-2 and 124 pounds, with a his- tory significant for hypothyroid, GERD, asthma (not well controlled) and recent (8 months ago) deep vein thrombosis (DVT). The patient is taking Coumadin for her DVT. You have some concerns about this patient so you call the surgeon's nurse practitioner, Diane. You discuss your concerns regarding potential blood loss for this case, especially since the surgery center has no blood bank. The closest hospital with a blood bank is 17 miles away. Diane reassures you that Dr. Smith has fixed 2 proximal humerus fractures in the past at this very surgery center and that the patient discontinued her Coumadin 3 days ago. Diane says she'll call the surgeon to express your concerns. She calls back and says that Dr. Smith understands your concerns and is willing to consider giving the patient tranexamic acid to prevent any bleeding. You check with the chief administrator of the surgery center to obtain a list of cases that are approved for this center. A humerus fracture is not on the list. How do you proceed? Tranexamic acid is an antifibrinolytic. It works by preventing blood clots from breaking down too quickly. This helps to reduce excessive bleeding. You should not use tranexam- ic acid if you have a history of blood clots. I would give the utmost attention to cases scheduled in a freestanding surgery center (no blood bank) that are not amenable to a tourniquet. If significant bleeding is antici- pated, I would consider performing the case in another facility because a situation in which there is substantial blood loss may require an urgent transfer. The asthma is another concern. This patient will likely require an endotracheal tube because of the potential for blood loss and the positioning (likely beach chair). YOU MAKE THE CALL Would You Do This Case?