human
Thank you.Do you always do a heparin bridge or is this contraindicated under certain situations?Does a patient history of a-fib affect the outcome of the risk calculus?
gpt
When considering the decisions here, you need to weigh the benefits and risks of anticoagulation.His stroke risk from afib can be estimated with the CHADS2-VASC score. Look this calculator up online. Most people stand an annualized risk of 2-11% of experiencing stroke. On a day to day basis, that risk is super small. Like 0.001% chance of having a stroke every day he's off anticoagulation, and even that is probably an overestimate of his stroke risk.The risks of bleeding are obvious. He's bleeding into his GU tract. This could occlude his bladder. He could bleed into the wound bed in ways that make his recovery worse. The chance of bleeding while anticoagulated is 100%.The last nail in the coffin is that we have multiple large and well-designed trials (BRIDGE and PERIOP2) that show no benefit to bridging pre or postoperatively in any population we've looked at this far, including mechanical valves in the post-op setting.At this point the only cases where bridging might be worth it is acute DVT/PE within 3 months of surgery, and maybe mechanical mitral valve.
Nephrology says it's probable stones and/or renal papillary necrosis.s.ne. There's a constant dull ache and then like a colicky pain that gets really bad really fast. It feels very similar to past kidney stones. The pain is on both flanks and spreads to my side right above my hip.I've had a couple of CTs. The last one showed at least one itty bitty stone. There's a constant dull ache and then a colicky pain that gets really bad really fast. It feels very similar to past kidney stones.I've done heat, cold, narcotics, NSAIDS (which the nephrologist said to stop) Ive done physical therapy, exercise, and stretching.The urologist says he didn't see anything and that I'm being dramatic.My PCP says there is something wrong and to see urology.Nephrology says its probable stones and/or renal papillary necrosis.The pain clinic says Im being dramatic
I agree that NSAIDS and opiates are not the way to manage this, and I believe your pain you are not "dramatic".How high is your calcium? Your hyperparathyroidism is possibly the most crucial thing to get under control. Chronic hypercalcemia obviously predisposes to stones, but also to a disease called nephrocalcinosis which can be painless but sometimes causes marked pain as small rocks of calcium get lodged in the draining portion of the kidney.The other not mutually exclusive possibility is you are having ureteral spasms, which are associated with hyperparathyroidism and hypercalcemia but no stones.So it is crucial to get your hyperparathyroidism under control. Even with "normal" calcium this can cause kidney problems and with hypercalcemia can cause kidney failure. If this is already under control then possibly it will get better once the ongoing calcium deposition improves. Dietary changes can also decrease calcium deposition, your nephrologist can advise on these.There are several medications available that are somewhat helpful for ureteral spasms including oxybutynin and tamsulosin but would focus on the underlying cause.