1. Cataract surgery should be bloodless. Either a phaecoemulsification or
ECCE (extra capsular cataract extraction) is invariably done through a
corneal section (incision). The only possible exception is if the patient
had a combined cataract/trabeculectomy - this should be obvious as there
will be a visible bleb or scar over the sclera + the patient should know!
2. If it is a bloodless operation it is not a contraindication to
thrombolysis. In Manchester, warfarin is not stopped prior to ( predicted to
be uncomplicated) cataract surgery for the same reason.
3. This information could have been discussed with the Ophthalmic SpR on
call who would know much more than the Medical team about cataract surgery.
4. If still in doubt then the patient could have had an urgent coronary
stent put in instead.
5. As with all thrombolysis patients informed consent is essential. I would
warn the patient that it is possible that bleeding could occur and that the
eye may be lost. It is a risk:benefit scenario - it is an inferior rather
than an anterior - but she is still young, the infarct appears to be of
recent onset as only 30 mins chest pain. (did she have Q waves, what was her
CK rise?)
6. This is potentially a very important decision for this lady - why was it
made at such a junior level? Not all thrombolysis decisions are
straigthforward, it is the difficult ones where we have the potential to
really improve thrombolysis rates. These are the type of situations where
one can
argue strongly for a senior presence on the shop floor of A+E departments.
I would have given her the Strep (as long as consent gained).
Simon
Simon Carley
SpR in Emergency Medicine
Hope Hospital
Salford
England
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-----Original Message-----
From: Mark Dawes <[log in to unmask]>
To: [log in to unmask] <[log in to unmask]>
Date: 12 November 1999 23:39
Subject: Thrombolysis Dilemma
>Dear all
>
>I would welcome your opinions on the following case.
>
>A 59 year old lady with a PMH of asthma, presented to A&E at 23.51 hrs via
>ambulance with a 30mins history of central crushing chest pain of rapid
>onset, with radiation to left arm and jaw.
>All relevant observations were carried out, oxygen therapy continued and 12
>lead ECG obtained.
>
>BP 135/70 Pulse 84 RR 18 SpO2 100% (with 4l O2)
>
>ECG showed 2-3mm elevation in the inferior leads and reciprocal changes in
>all the anterolateral leads.
>
>Aspirin 300mg, Nubain 10mg and Metoclopramide 10mg had been given by the
>paramedic crew. The patient was still distressed in A&E and received
>Diamorphine 5mg.
>She seemed an excellent candidate for Streptokinase but on questioning for
>contraindications, she admitted to having right cataract surgery 2 weeks
>ago.
>This caused the dilemma of whether or not to give her Streptokinase therapy
>in the department as our guidelines suggest that it is contraindicated in
>those who have undergone any operation in the past 6 weeks.
>The medical SHO advised against thrombolysis and the patient was
transferred
>to CCU.
>
>My questions are-
>1) Would any of the group have gone ahead and Strep'd anyway?
>2) Are there some surgical procedures that should only be a relative
>contraindication?
>3) Should the patient be given the option of whether to be treated,
with
>the risks to her sight being explained? (The
>CCU didn't give the patient the option - as they felt it was unfair to
>place a decision that she may not fully understand the implications of on
>her).
>
>I felt that the possibility of losing the sight in one eye was less
>detrimental to her overall health than having a large segment of damaged
>myocardium!!??
>
>I look forward to receiving your comments.
>
>Mark Dawes
>Charge Nurse
>A&E Dept, Manor Hospital, Walsall
>
>
>
>
>
>
>
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