Interesting case from this week

[bcat85]

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A middle aged man with terminal lymphoma of the leg presents for palliative hip disarticulation vs. hemipelvectomy for severe pain and chronic no healing wound infections. PMH is significant for HIV infection, HTN, and 50 pound weight loss over the previous 6 months. Lab work shows a platelet count of 24k, a hct of 22, and an albumin of 2.0. How would you proceed?

 

[Precedex]

A middle aged man with terminal lymphoma of the leg presents for palliative hip disarticulation vs. hemipelvectomy for severe pain and chronic no healing wound infections. PMH is significant for HIV infection, HTN, and 50 pound weight loss over the previous 6 months. Lab work shows a platelet count of 24k, a hct of 22, and an albumin of 2.0. How would you proceed?

Big ivs, Aline, lots of blood products .

 

[sevoflurane]

A middle aged man with terminal lymphoma of the leg presents for palliative hip disarticulation vs. hemipelvectomy for severe pain and chronic no healing wound infections. PMH is significant for HIV infection, HTN, and 50 pound weight loss over the previous 6 months. Lab work shows a platelet count of 24k, a hct of 22, and an albumin of 2.0. How would you proceed?

Retrograde wire.

 

[BobBarker]

MAC catheter, RIC, 16g. Belmont. A line bilateral radials. Start infusing blood, platelets, ffp through Belmont and Mac at induction and don't stop. Be ready to implement mass transfusion protocol at any moment. I have done this case and gave over 150 total units of product.

 

[sevoflurane]

All kidding aside, with the 50 lb weight loss over the last 6 months... what is the end point of the operation? Sounds like he's almost there.

I've done a couple of hemipelvectomies in the past. These are big multidisciplinary cases that have the potential for badness. Sounds like he's pancytopenic and malnourished. These are real challenges intra and post-op.

I think Precedex and Bbaker nailed it. Stay ahead of the coagulopathy. These can have a ton o of oozing as well as brisk hemorrhage.

Great case.

 

[urge]

Palliative care consult. Done.

If they fuss about it, I need the case approved by the chair of ortho, hiv attending, and onco attending, in writting.

 

[urge]

MAC catheter, RIC, 16g. Belmont. A line bilateral radials. Start infusing blood, platelets, ffp through Belmont and Mac at induction and don't stop. Be ready to implement mass transfusion protocol at any moment. I have done this case and gave over 150 total units of product.

Why 2 radials? Its not like you will perfuse one side and not the other. If one goes because of vasoconstriction the other one is done also.

 

[BobBarker]

Two radials because I had one on my case and wished I had two. About 30 istat cartridge draws will bag almost any radial line.

 

[polar403]

Two radials because I had one on my case and wished I had two. About 30 istat cartridge draws will bag almost any radial line.

What about blood draws from the central line if you've got large bore peripheral IVs?

 

[BobBarker]

Sure. But to give 150 units in 6 hours you are going to be using all of your access.

 

[BobBarker]

This is one of those cases where at the end you are either thinking "thank god we got all of that access" or "we could have done this off of a good IV and an art line". Probably won't be in between. My case was a hemipelvectomy for sarcoma resection. I had an art line, a cordis, a 20g (came with it), an 18g, a 16g, and a 14g (ran like an 18, bent in the the AC of the up arm) and we used all of the access with the Belmont and Level 1 both deployed.

 

[Trisomy13]

Never mind. Saw my error. 🙂

 

[Spinach Dip]

Palliative care consult. Done.

Whimp.

Retrograde wire.

Good idea, but why not just go straight to tracheostomy? This guy's probably gonna need it sooner or later.

 

[Apollyon]

Good idea, but why not just go straight to tracheostomy? This guy's probably gonna need it sooner or later.

It's an old school joke - that's why he put it up there standing all alone. (I don't know if searching for it would be fruitful in finding the old thread(s) about it.)

 

[Spinach Dip]

It's an old school joke - that's why he put it up there standing all alone. (I don't know if searching for it would be fruitful in finding the old thread(s) about it.)

LOL. I know. That's why I said it was a good idea. XP

 

[BobBarker]

I think you could do this one with a carefully titrated IT cath.

 

[lobelsteve]

What a waste of tax dollars, time, and effort.
Gimme $5k and a port. He has days to weeks and needs comfort, not $1 million dollars worth of care.
IV dilaudid, ativan.

 

[bcat85]

Big ivs, Aline, lots of blood products .

This was essentially my plan. I had planned to transfuse platelets preop and place 2 PIV's, a MAC, and an art line with the Belmont ready to roll.

The patient came to preop and labs showed a sodium of 122 with worsening thrombocytopenia and HCT so we cancelled the case. He was admitted to onc for management, worsened over the weekend, and was discharged to hospice. All-in-all, I thought it was the best outcome for the guy. Better to die at home than stuck in the ICU.

 

[urge]

This was essentially my plan. I had planned to transfuse platelets preop and place 2 PIV's, a MAC, and an art line with the Belmont ready to roll.

The patient came to preop and labs showed a sodium of 122 with worsening thrombocytopenia and HCT so we cancelled the case. He was admitted to onc for management, worsened over the weekend, and was discharged to hospice. All-in-all, I thought it was the best outcome for the guy. Better to die at home than stuck in the ICU.

I'm glad for the patient.

Anybody who thought this case was appropriate needs to have their head checked.

 

[Bostonredsox]

What a waste of tax dollars, time, and effort.
Gimme $5k and a port. He has days to weeks and needs comfort, not $1 million dollars worth of care.
IV dilaudid, ativan.

This is the correct answer. Without even knowing his complete staging and days into diagnosis a pt getting a hemipelvectomy for end stage lymphoma has <3,months. Put a port in, consult hospice and start him on a dilaudid pump. Don't wast a hundred thousand in tax care dollars for something a few hundred dollars worth of narcotic can also achieve. This is a big reason why our healthcare system is going bankrupt. Lack of true palliative care. Surgeons should have refused this case.

 

[pgg]

This was essentially my plan. I had planned to transfuse platelets preop and place 2 PIV's, a MAC, and an art line with the Belmont ready to roll.

The patient came to preop and labs showed a sodium of 122 with worsening thrombocytopenia and HCT so we cancelled the case. He was admitted to onc for management, worsened over the weekend, and was discharged to hospice. All-in-all, I thought it was the best outcome for the guy. Better to die at home than stuck in the ICU.

Glad to hear that.

Any time anyone considers Hospice, it's usually the right answer.