CABG in am and on Plavix? I don't get it

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I am preparing my patient for CABG in AM:

EKG done,bloods drawn (CBC, chem7, Coags, & crosshatch for 4units, type and screen)

CxR done, 1st shower with antimicrobial soap done, Swabs done( MRSA,VRE,etc), Weigh patient, Set up telemetry, NPO @ Midnight, Echo to do in am.....

So now I get to my medication list and find out that patient received Effient drug in emerge this morning. (This drug is the equivalent to PLAVIX). Now I know that it's supposed to be stopped 7 days before OR on our floor. I call the doctor to tell him, thinking that the OR will be cancelled but he agrees to go ahead with the surgery anyways. I made sure to document it in my notes. I was told that the reason you stop Plavix days before surgery was to decrease or prevent post-operative bleeding.

So my question is this I've seen patients scheduled for CABG in A-fib on a heparin drip till 6am. (2 hours before surgery). AREN'T THEY AT INCREASED RISK OF POST-OPERATIVE BLEEDING Too? Why all the big fuss about Plavix.

Why is more importance put on the patient who is not suppose to Be taking PLAVIX pre-op. I know it's an anti platlet but doesn't it also act as an anticoagulant/blood thinner? To prevent clot formation or platlet aggregation?

Please enlighten me......Thanks

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Specializes in RETIRED Cath Lab/Cardiology/Radiology.

Half life of heparin is approx. one hour, which means discontinuing it two hours preop means effects of its anticoagulation properties will be almost gone by the time the pt is delivered and prepped for surgery.

Plavix's half-life is six hours, with variable effects of its anticoagulation properties (recovery time for the platelets).

Here is a study about that: Recovery of platelet function after discontinuation of clopidogrel treatment in healthy volunteers

If the Plavix given in the ED was single-dose (the patient's first dose -- he had NOT been on daily Plavix dose at home), the surgeon may have felt the benefit of doing the surgery was worth the risk of bleeding, in this one case.

In general I believe the CT surgeons make it a practice to reschedule surgery if the pt has been on routine doses of Plavix within 4-7 days of surgery.

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Specializes in OR, Nursing Professional Development.

Also, cabg patients are routinely heparinized in the or for cardiopulmonary bypass. We can also give protamine to reverse the effects of heparin. However, if a patient is in house his/her condition may warrant the surgery prior to the ideal time off plavix. That's the surgeon's call to make.

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Why all the big fuss about Plavix.

Why is more importance put on the patient who is not suppose to Be taking PLAVIX pre-op. I know it's an anti platlet but doesn't it also act as an anticoagulant/blood thinner? To prevent clot formation or platlet aggregation?

Plavix is a platelet aggregation inhibitor. Heparin is an anticoagulant. Both work to prevent clots, but in different parts of the process. Platelet aggregation triggers the clotting cascade, so Plavix acts on an earlier part of the process since it inhibits platelet aggregation.

The patient in question received a loading dose of Effient in the ED, which will have a half life of about 7 hours. It takes about 5 days of repeated dosing to achieve a steady state. It sounds like the benefits of CABG sooner outweighed the potential risks involved. In other words, he needs the surgery now to restore blood flow to the myocardium, and the risks of waiting are greater than the risk of bleeding associated with the Effient.

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Thank you for your responses. I understand it so much clearer now. The last I heard about the patient was that he was in ICU with a balloon pump (IABP) for low cardiac output following the surgery. So I gather that he wasn't doing too good. Well after ICU I hope to see him back on the floor soon post-op. thanks again you nurses are amazing. I luv this site.

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The patient in question received a loading dose of Effient in the ED, which will have a half life of about 7 hours. It takes about 5 days of repeated dosing to achieve a steady state.

We had the Effient reps in last week, and I have the literature in front of me, because I was curious about this too. Effient reaches the therapeutic level of about 75% platelet inhibition in about 2 hours with a loading dose. And since it's an irreversible agent, binding to the platelet for the life of the platelets (around 7 days), it doesn't matter that the half life of the drug is 7 hours, because the effect won't wear off completely for about 5-9 days while inhibited platelets die off. Actually in the first 24 hours, inhibition only drops a few percentage points, which is really good for a once a day drug.

I worried if these guy bleed though, all you can do in stop the drug and dump more platelets in them, right?

edit: added a little more.

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Ah, thanks.

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On a side note, I recently had a pt on Plavix & ASA, and scheduled for a valve replacement in a couple of days. I checked with the surgeon about this, and he said to continue it because the pt had a recent stent, so he felt the benefits outweighed the risks.

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Specializes in RETIRED Cath Lab/Cardiology/Radiology.

ALWAYS: risk VS benefit.

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