Date: Mon, 3 Feb 2003 09:21:40 -0500

Subject: Plavix (Clopidogrel) Experience

To All,

I am hopeful that some of the list participants have experienced the potential frustration that can come with fracture patients on Plavix; and be willing to offer some comments. This anti-platelet drug is being used with rapidly increasing frequency. Now that I see it advertised on the nightly news, I'm sure this trend will only intensify. I have several questions/observations. Fractures can be divided into the 'able to wait' and 'not so able to wait' categories. The solution seems relatively obvious in the 'able to wait' category - stop Plavix, splint, repair fracture in 7 to 10 days (unless medicine MD says no way on Plavix stoppage). The 'not so able to wait' category is a bit more complex. Most anesthesiologists (my experience) are very reluctant to perform regional/spinal procedures on Plavix patients (probably extrapolation from LMWH data). These patients (hip fractures) are often poor candidates for general anesth. Here come the questions:

1. Are you willing to proceed with the orthopaedic procedure in the face of Plavix if anesthesia proceeds with general?

2. Opinions on platelet transfusion (the only antidote) then proceeding with the ortho procedure, +/- how this affects the anesthesia plan.

Obviously, various combinations of the above scenarios can make this a long discussion, but I would greatly appreciate any thoughts/previous experience. This may be very straightforward in everyone's mind. If so, that makes it more simple. We are currently trying to establish some practice guidelines at MCG. Thanks very much for your time and effort.

Mike

Michael C. Tucker, MD
Director, Orthopaedic Trauma Service
Assistant Professor of Orthopaedic Surgery
Department of Orthopaedic Surgery
Augusta, GA 30912

Date: Mon, 3 Feb 2003 11:18:18 -0500

From: James Carr

Hey Mike

It fortunately has not raised its ugly head 75 miles up the road from you. Sounds like it needs some science. I remember the days of the preop sickle cell trait- if positive, we would then get the electrophoresis. Fortunately turned out to be an idea that made some intuitive sense, but had no basis in reality. What they say makes sense, but needs data, not dogma. Jim Carr

James B. Carr, MD
Palmetto Health Orthopedics

Date: Sun, 9 Feb 2003 23:11:43 -0600

From: Obremskey, William T

Mike,

I would procede w/o spinal for a hip fx. We often say that the M&M for a general is greater than a spinal, but I know of no data that supports this. The Cochran Collaboration has looked at this in a meta-analysis and found no differences. (See www.cochranelibrary.com - Anaesthesia for hip fracture surgery in adults (Cochrane Review), Parker MJ, Handoll HHG, Griffiths R.).

Due to mixing of platelets and high immunologic load, I would not use platelets unless absolutely necessary or bleeding was bad intra or post op.

Bill

William T Obremskey MD MPH
Vanderbilt University
Orthopedic Trauma Division
Nashville, TN 37232-3450