Case for discussion

[Noyac]

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37 yo previously healthy until 2 wks ago when she had 2 separate surgeries for what was thought to be a pelvic abscess from IUD involving the uterus and fallopian tube. The second surgery was performed b/c of bowel perf from previous surgery 24 hrs earlier. It was noted during the second surgery that she actually had grade 4 colon CA. Pt recovers well and 2 weeks later comes to ASC for Port-a-cath placement. She is found to have RA sats of low 80's and she c/o left sided chest pain like a pulled muscle. O2 by nasal cannula and sats are 90%.

Do you do the case?

 

[msgbueno]

given her recent diagnosis of stage 4 colon ca, the port a cath placement is for palliative purposes. although this case will most likely be under MAC, maybe even local only, a medical consult would be wise. this case is not an emergency, and does not need to be done in any immediate time frame. in fact, you should send her immediately to the ED for ACS work up.

 

[Planktonmd]

37 yo previously healthy until 2 wks ago when she had 2 separate surgeries for what was thought to be a pelvic abscess from IUD involving the uterus and fallopian tube. The second surgery was performed b/c of bowel perf from previous surgery 24 hrs earlier. It was noted during the second surgery that she actually had grade 4 colon CA. Pt recovers well and 2 weeks later comes to ASC for Port-a-cath placement. She is found to have RA sats of low 80's and she c/o left sided chest pain like a pulled muscle. O2 by nasal cannula and sats are 90%.

Do you do the case?

PE?
Pulmonary mets?
Let them do the port under local then send her to the ER for workup.

 

[proman]

Could be PE or malignant effusion. The chemo can wait, to the ER.

I see Plankton beat me to PE. That's a potentially life-threatening condition that should not wait for a non life-saving intervention. I'd go effusion since it sounds like an insidious onset.

 

[huktonfonix]

hmmm, no. Left sided chest pain suggests the possibility of a left sided pulmonary lesion whether its a PTX, or effusion. A port with likely right sided insertion is a bad idea all around. Chemo can be given with peripheral access or a femoral line if need be. Right now they need to work up her hypoxia.

 

[aredoubleyou]

Sounds like a good chance somethings developing near her left diaphragm like an effusion or even a pneumo from her abdominal exploratory surgery. Assumming the hypoxia is new its likely to be something that can develop quick like effusion, pneumo, PE, less likely mets, pneumonia, pulm oedema, etc given the pain. Either way she needs a CXR probably followed by a CT and some type of intervention before the surgeon starts poking new holes in her chest.

 

[militarymd]

blah...it's skin surgery....

I would tell the surgeon to put it on the left side....and take a quick look with fluoro while in OR....

Admit to hospital procedure for workup.

 

[Noyac]

blah...it's skin surgery....

I would tell the surgeon to put it on the left side....and take a quick look with fluoro while in OR....

Admit to hospital procedure for workup.

Hey Mods, can I request a ban on Mil for my cases?

This is what my partner did.

I'm pretty sure it was a PE. I wasn't involved in this case. I did her second case when she was septic.

 

[mille125]

why subject this dying lady to a long protracted workup..what are you going to do if you find an MI or PE (stents, thrombolytics).....come on...do the case under local and let her get her treatment..........

 

[Noyac]

why subject this dying lady to a long protracted workup..what are you going to do if you find an MI or PE (stents, thrombolytics).....come on...do the case under local and let her get her treatment..........

Well you are right to some extent but if it is a PE, we can prevent further PE's. But dying from a massive PE may be better than dying from colon CA.