Anti-Clotting Meds Don't Increase GI Surgery Bleeding Risk

Concerns that patients who take anti-clotting drugs before surgery to remove lesions from the digestive tract are at greater risk of bleeding are largely unwarranted, according to a Mayo Clinic study.

Aspirin, NSAIDs and anti-coagulates like clopidogreal (Plavix) do not increase bleeding risks during or after lesion removal from the esophagus, stomach or colon, says Bashar Qumseya, MD, a second-year gastroenterology fellow at the Mayo Clinic in Jacksonville, Fla., and lead author of research presented at the annual meeting of the the American College of Gastroenterology last week.

Bleeding occurred during almost 4% of about 1,300 endoscopic mucosal resections - a minimally invasive procedure that removes lesions from the digestive tract - performed at the Mayo Clinic between 1999 and 2010.

The researchers discovered the intra-procedure bleeding was linked to removal of lesions in the stomach and esophagus; post-procedure bleeding, which occurred in nearly 3% of patients, was associated with the removal of lesions 5cm or larger from anywhere in the digestive tract, notes the study. The researchers, however, found no link between anti-inflammatory and anti-clotting agents and increased risk of bleeding that occurred during or after procedures.

"There has been a lot of discussion in the medical community about what to do with people on these medications, and we are pleased to find this early study suggests there may not be the risk of bleeding we once thought would occur," says Mayo Clinic gastroenterologist Timothy Woodward, MD.

Daniel Cook

Other Causes of MH Explored

While occurrences of malignant hyperthermia are usually caused by exposure to general anesthesia, the potential for an episode to be triggered by other factors such as heat, extreme exercise or febrile illness has been demonstrated in certain breeds of swine, say researchers.

In a study published in the November issue of the journal Anesthesiology, researchers from the University of Rochester, University of Pittsburgh, Uniformed Services University and National Institutes of Health provide evidence that this phenomenon can occur in humans.

The team reported 2 fatal cases of "awake" malignant hyperthermia induced by heat stress in children, and refer to a third similar case. The investigators carefully documented the MH-like signs and symptoms in these children, examined their DNA changes and tested the effects of these challenges on cellular physiology. Results from this study support the linkage of the DNA changes with these "awake" MH episodes.

Still, researchers noted that these findings don't necessarily mean that MH-susceptible individuals, especially children, are at particular risk for heat-induced MH episodes. Until more data is available, it is difficult to advise MH-susceptible individuals about the avoidance of vigorous exercise and/or extremely hot environments.

Genetic or DNA changes most commonly associated with susceptibility to MH are found within the gene called the ryanodine receptor. There are hundreds of DNA changes in this very large gene, and some are clearly causal for MH. Additional factors such as the patient's age, presence of more than 1 DNA change, an existing medical condition, or the addition of an environmental stressor such as exercise, heat stress or febrile illness may affect the likelihood that a life-threatening MH episode will occur.

Understanding the mechanisms behind anesthetic and non-anesthetic induced MH "will lead us to potential treatments and better patient care," says lead author Robert T. Dirksen, PhD, of the University of Rochester.

Mark McGraw

Good Ideas For GI Efficiency

Improving the performance, patient safety and profitability of your facility's GI service doesn't take a lot of work to accomplish. A bit of advance planning and a few small changes can make a big difference, say Nurse Administrator Michelle Steele, BSN, CGRN, of the Eastside Endoscopy Center in Bellevue, Wash., and Administrator John Gleason, MMHS, CASC, of the Berks Center for Digestive Health in Wyomissing, Pa.

In "15 Secrets of High-Performing GI Centers," published in October's Outpatient Surgery Magazine, they outline the steps that have brought them improved results.

The article includes tips on staggering start times for procedures and staff, scheduling and equipping for more efficient reprocessing, open access and wait-lists to optimize OR utilization, and how CO2 and PACU furniture can affect recovery, among other advice.

David Bernard

InstaPoll: Are You Satisfied With Medicare's 2012 Rates?

Medicare reimbursements to hospital outpatient departments will rise 1.9% and payments to ambulatory surgery centers will jump 1.6% in 2012. Tell us what you think of these planned rate increases in this week's InstaPoll. We'll report the results in this space next week.

Forty percent of the 387 facility managers who took last week's InstaPoll forbid the use of cell phones in the OR. For most, however, talking and texting in the middle of a case is OK under certain circumstances. The responses:

  • In moderation, cell phones in the OR are OK: 24%

  • Only for work-related calls and texts: 35%

  • Everybody does it - plus, what's the harm? 1%

  • We forbid their use: 40%

    Cell phones should never leave the locker room, as far as Phenelle Segal, RN, CIC, is concerned. "I have observed employees standing in the suite during a case, using their cell phones and not practicing any hand hygiene thereafter," says Ms. Segal, president of Infection Control Consulting Services in suburban Philadelphia. "If someone needs to make a call, they can go to the locker room when time permits."

    Another poll found that nearly two-thirds (64%) of the 108 respondents have suspected a physician of being under the influence of drugs or alcohol while in the OR.

    Dan O'Connor

  • News & Notes
  • Does Mozart make a difference? A recent study performed by researchers at the University of Texas Health Science Center at Houston speculates that playing Mozart while your endoscopists work may increase adenoma detection rates. Researchers observed the work of 2 experienced endoscopists as they randomly piped in the classical composer's works or let the physicians work in silence. They found that "both endoscopists had higher adenoma detection rates listening to music when compared with their baseline rates."

  • Walking test predicts outcomes Elderly patients who walk fast fare better than their slow-walking peers following colorectal and cardiac surgeries, according to research conducted at the University of Colorado in Denver and presented last month at the American College of Surgeons' annual clinical congress. Researchers asked 195 patients aged 65 years and older to stand up from a chair, walk 10 feet, then return to the chair. Individuals able to complete the test in 10 seconds or less were classified "fast"; patients taking 15 seconds or longer were labeled "slow." The study demonstrates that walking speed is a marker of physical frailty, according to the researchers, who are trying to develop "simple tools that the average surgeon can use to determine who is going to fare poorly after an operation."

  • Tip of the week Make sure your anesthesia providers take part in your wrong-site prevention efforts. Have them tape a "time out" label over the thumb insert of their nerve block syringes, which serves as a noticeable reminder to verify injection sites before they administer the drugs. "It's a simple but effective way to add redundancy to the process," says Eduardo D'Agostino, MD.
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