A new case

[cchoukal]

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69 yo M w/ esophageal CA, s/p feeding J-tube and neo-adjuvant chemo, now presenting for lap, trans-hiatal esophagectomy.

Since his chemo started 4 months ago, he has had epistaxis requiring transfusion, dysphagia requiring chronic tube feeds, and has been in a subacute nursing facility. Patient is pre-admitted from a nursing home the Friday before the case, and is noted to have a new pericardial and pleural effusion, and the EKG, which used to show accelerated junctional, now shows flutter with 4:1.

What do you need to see/know/have happen in order to agree to do the case?

 

[Spinach Dip]

What do you need to see/know/have happen in order to agree to do the case?

That I wont lose my job/get sued if he dies on the table.



Other than that, retrograde wire.

 

[Surfer]

High risk. Sounds like a case for hospice. But if they insist, i explain that he is very, VERY high risk for death or other morbidity. Then I talk with the surgeon and come up with a plan. Then we do it. This guy doesn't have very long to live. If he dies on the table (which he won't) then his family will be somewhat relieved that his suffering is over. If he does fine during the surgery then no sweat. Cases like this aren't super terrible because typically everybody understands you're throwing a hail mary.

 

[sevoflurane]

69 yo M w/ esophageal CA, s/p feeding J-tube and neo-adjuvant chemo, now presenting for lap, trans-hiatal esophagectomy.

Since his chemo started 4 months ago, he has had epistaxis requiring transfusion, dysphagia requiring chronic tube feeds, and has been in a subacute nursing facility. Patient is pre-admitted from a nursing home the Friday before the case, and is noted to have a new pericardial and pleural effusion, and the EKG, which used to show accelerated junctional, now shows flutter with 4:1.

What do you need to see/know/have happen in order to agree to do the case?

Vitals
BMP/LFTs/CBC with diff/Coags (transfusion for a nose bleed needs worked up). Pre-albumin for protein/calorie malnutrition.
CXR
Cards consult with new arrythmia + Echo eval post chemo and in the setting of new pericardial effusion.

 

[deleted171991]

What sevo said. I wouldn't care about the effusions if they were small, and functionally insignificant (would fix them otherwise). What I don't like is the flutter; that needs to be either cardioverted, ablated, or otherwise chronically-controlled (including anticoagulation).

Generally-speaking, I want this patient to be optimized pre-op to his best possible baseline before attempting this surgery. Almost like preparing a used car for sale. This is a palliative surgery, most likely. The patient should be explained that the morphine drip is a more pleasant way to die.

 

[urge]

69 yo M w/ esophageal CA, s/p feeding J-tube and neo-adjuvant chemo, now presenting for lap, trans-hiatal esophagectomy.

Since his chemo started 4 months ago, he has had epistaxis requiring transfusion, dysphagia requiring chronic tube feeds, and has been in a subacute nursing facility. Patient is pre-admitted from a nursing home the Friday before the case, and is noted to have a new pericardial and pleural effusion, and the EKG, which used to show accelerated junctional, now shows flutter with 4:1.

What do you need to see/know/have happen in order to agree to do the case?

I need a note recent from the oncologist saying he has meaningful recovery if the tumor is removed. Cardiology consult to help manage the arrhythmia and an echo post chemo. I would have no problem proceeding if there above 3 were properly documented. I don't think there is much room for optimization.

 

[lobelsteve]

Cancel. Adequate port? Hospice or palliative consult.

Wasting money and resources. Cruel to not let patient die at home with some dignity.

 

[urge]

Cancel. Adequate port? Hospice or palliative consult.

Wasting money and resources. Cruel to not let patient die at home with some dignity.

Aren't you PM&R? What say do you have in this?

 

[lobelsteve]

Aren't you PM&R? What say do you have in this?

PMR trained, Pain fellowed. And I pay taxes. You guys are personally costing me with all of this "awesome" life saving care.

Some anesthetic plans are not to provide anesthesia.
Some PMR plans are not to inpatient rehab. We don't get to say no to a surgery, but we can send people home or to a SNF.

How long is this guy going to live with no surgery?
How long is this guy going to live with this surgery?
How much QOL will he have post-op and recovery, and when will he be able to enjoy that QOL?

 

[Beargryllz]

PMR trained, Pain fellowed. And I pay taxes. You guys are personally costing me with all of this "awesome" life saving care.

Some anesthetic plans are not to provide anesthesia.
Some PMR plans are not to inpatient rehab. We don't get to say no to a surgery, but we can send people home or to a SNF.

How long is this guy going to live with no surgery?
How long is this guy going to live with this surgery?
How much QOL will he have post-op and recovery, and when will he be able to enjoy that QOL?

I say we just kill all the patients and save ourselves a boatload

Why settle for just culling the oldest and weakest when we can eliminate the rest of the burden with it?

 

[lobelsteve]

I say we just kill all the patients and save ourselves a boatload

Why settle for just culling the oldest and weakest when we can eliminate the rest of the burden with it?

Bear: it was that exact attitude thay made you a pocket knife salesman and got your show cancelled.

My questions are reasonable and should be answered as part of any surgical plan.

http://onlinelibrary.wiley.com/doi/...sCustomisedMessage=&userIsAuthenticated=false

http://m.ejcts.oxfordjournals.org/content/24/4/631.short


Survival from surgery is likely as is 3 year mortality appears 50/50 based on cursory review of literature as out of scope physician. (Onc, onc surg, GI) Do we want to know more about QOL before consenting this gentleman with minimum 4% chance of dying in OR?

 

[cchoukal]

Vitals
BMP/LFTs/CBC with diff/Coags (transfusion for a nose bleed needs worked up). Pre-albumin for protein/calorie malnutrition.
CXR
Cards consult with new arrythmia + Echo eval post chemo and in the setting of new pericardial effusion.

146/68, 75, 20, 96% RA.

BMP pretty NL. K inexplicably 4.9, but bicarb 27, Cr 0.5
LFTs NL
CBC: Hb 9, plts 250
Alb 2.9, pre-alb 12.

TTE, other than the effusion and Flutter, was pretty NL, with good LV fxn, EF 0.65, NL valves. Pericardial and pleural effusions drained (assumed to be 2/2 chemo and XRT).

Interesting that everyone assumed this was palliative, or that his survival was limited. His lesion is T3N1M0, and the PET did not show any distant disease.

 

[Spinach Dip]

PMR trained, Pain fellowed. And I pay taxes. You guys are personally costing me with all of this "awesome" life saving care.

Some anesthetic plans are not to provide anesthesia.
Some PMR plans are not to inpatient rehab. We don't get to say no to a surgery, but we can send people home or to a SNF.

How long is this guy going to live with no surgery?
How long is this guy going to live with this surgery?
How much QOL will he have post-op and recovery, and when will he be able to enjoy that QOL?

I didn't know this thread was about the cost/benefit analysis to the taxpayers.

I thought we were discussing how a specific ASA4.9 patient was to be treated.

 

[urge]

146/68, 75, 20, 96% RA.

BMP pretty NL. K inexplicably 4.9, but bicarb 27, Cr 0.5
LFTs NL
CBC: Hb 9, plts 250
Alb 2.9, pre-alb 12.

TTE, other than the effusion and Flutter, was pretty NL, with good LV fxn, EF 0.65, NL valves. Pericardial and pleural effusions drained (assumed to be 2/2 chemo and XRT).

Interesting that everyone assumed this was palliative, or that his survival was limited. His lesion is T3N1M0, and the PET did not show any distant disease.

Pent sux tube

 

[BLADEMDA]

146/68, 75, 20, 96% RA.

BMP pretty NL. K inexplicably 4.9, but bicarb 27, Cr 0.5
LFTs NL
CBC: Hb 9, plts 250
Alb 2.9, pre-alb 12.

TTE, other than the effusion and Flutter, was pretty NL, with good LV fxn, EF 0.65, NL valves. Pericardial and pleural effusions drained (assumed to be 2/2 chemo and XRT).

Interesting that everyone assumed this was palliative, or that his survival was limited. His lesion is T3N1M0, and the PET did not show any distant disease.

Honestly, he seems in better shape than many of my patients. I'm curious as to your plan for fluid optimization and postop pain management (thoracic epidural?) maintain Hgb above 8? Will you consider albumin IV intraop or just crystalloids? Preop ABG? History of COPD?

 

[sevoflurane]

Pre-albumin of 12 likely means he’s malnourished. He’s at increased risk for poor healing and infections as well as increaed risk for morbidity and mortality (more so for GI surgery).
He is tachypnic but room air sats are good. Did he have a recent CXR? What did the CT show?
He’s anemic. Prolly anemia of chonic disease, but we can’t ignore the fact that he recently received a tranfusion for a nose bleed. Did we get any coags?

Sorry, more quesitons than answers, but I think it can be safely said that this individual is at least moderate-high risk for post-operative complications.
Very high risk regarding 5 year survival.
As always, is he optimized? If so, then proceed.

 

[Noyac]

Well it's much easier for me to chime in after you guys gathered more info but here's my $.02.
I don't really care how malnourished he is since healing is the surgeons problem and if he wants to take that on then that's his business. As long as I think I can get him through this case safely, meaning heart and lungs are ok then I'm pretty much on board. If I'm the complete peri-operative physician as we may be in the future then I will address his malnutrition but I have a feeling that it's as good as it gets
Lobelsteve may have a valid point too but I would like to think that the surgeons all weighed these issues. It's not my place to throw a wrench in all the work that was done prior to me meeting this pt. With that said, I don't necessarily agree with the plan I would have addressed it in the pre-op clinic though. So I assume if he made it this far then all this has been discussed.
Like Sevo, I would want his coagulopathy, if there is one, addressed.