would you do this case?

[Jeff05]

47 year old female. advanced breast ca (3rd world nation style), palliative care/hospice. mets everywhere. the whole chest wall is covered in fungating tumor. to OR for some LASERing of tumor to control mild oozing. 99% sat on 4 L NC, shallow breathing at 22/min, BP/HR wnl. echo ef 43% (?), hct 28, cr 0.8, cxr with mass in LUL, fields reasonably clear, small b/l effusions. MP3, lots of loose teeth.


would you do this case?
what discussion if any would you have with the surgeon? with the patient?

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[Planktonmd]

47 year old female. advanced breast ca (3rd world nation style), palliative care/hospice. mets everywhere. the whole chest wall is covered in fungating tumor. to OR for some LASERing of tumor to control mild oozing. 99% sat on 4 L NC, shallow breathing at 22/min, BP/HR wnl. echo ef 43% (?), hct 28, cr 0.8, cxr with mass in LUL, fields reasonably clear, small b/l effusions. MP3, lots of loose teeth.


would you do this case?
what discussion if any would you have with the surgeon? with the patient?

What's the problem?

 

[Jeff05]

while preox her max TV (spont) is 250 mL.

after intubation difficult to ventilate (using pressure support at 35 getting in TV of about 300). restrictive pattern...

 

[Planktonmd]

while preox her max TV (spont) is 250 mL.

after intubation difficult to ventilate (using pressure support at 35 getting in TV of about 300). restrictive pattern...

When you say pressure support of 35 I assume you mean you are maintaining spontaneous ventilation and using SIMV or something like that?
She probably has pleural effusions that could have been drained preop and multiple metastatic lesions in the lungs making them stiff.
I would paralyze the patient and use controlled ventilation.

 

[zippy2u]

Ask surgeon how much money he will get from doing this case. Oh, $250? Write out a check for $250 from your checking account, hand it to him and tell him to cash it. Go to pt. and tell her she's too high risk and tell her ya got somethin' better for her--- a bag of morphine pills and a box of 4X4s to take care of the oozing. Regards, ---Zippy

 

[Jeff05]

sorry, pressure control ventilation. she is paralyzed.

zip, i like your style.