Med Mal: Kidney biopsy --> Hemorrhagic Shock --> Pressors --> 9 fingers amputated

[HemeOncHopeful19]

That is a convincing to a lay person but shouldn’t be to us. People check daily CBC in stable patients all the time who gives a **** what the results are if it isn’t relevant to what is going on. Same applies here—the levels weren’t back so they had the same amount of information any standard of care would have had which is to say none because it isn’t obtained outside of some narrow scenarios.

Yeah I’d really like to know what the Heme note said. For example, what if it said “check 4 hours after 3rd dose” and some hospitalist ordered Q4hours instead?

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[end stage fibro]

I usually write “can restart anticoagulation once felt safe from bleeding risk by surgeon/proceduralist” but in private practice people may get pissy about that.

As in the surgeon gets mad? I used to be pretty aggressive about starting AC after a procedure but now that I've got some experience under my belt I'm damn sure to discuss AC with the surgeon. The variability in their opinion is sometimes surprising

 

[Crayola227]

That is a convincing to a lay person but shouldn’t be to us. People check daily CBC in stable patients all the time who gives a **** what the results are if it isn’t relevant to what is going on. Same applies here—the levels weren’t back so they had the same amount of information any standard of care would have had which is to say none because it isn’t obtained outside of some narrow scenarios.

Yes, and I'm saying that sort of lazy ordering can open you up to a lawsuit. Physicians doing things that make sense to them but will look awful in a lawsuit can still be a problem to them, and as you keep saying, the labs weren't needed. This is a case where ordering unnecessary labs is NOT "defensive" medicine.

It creates a "gotcha." In fact, if abnormal labs had not resulted so late, I wonder if it's possible that the patient and med mal attorney would not have even seen an obvious avenue of attack and filed. It's possible they may not have. Easier to sell a narrative this was unavoidable and defend not ordering the labs.

The heparin gtt and nursing cost was cheaper in hindsight.

One thing that also made this case different was considering how you would reverse or treat for a bleed. One lesson learned, if they have Raynaud's pressors may be more problematic. So you may need to take greater care with bleeding risk, avoiding a bleed, or trying harder to treat without pressors.

 

[chessknt]

Yes, and I'm saying that sort of lazy ordering can open you up to a lawsuit. Physicians doing things that make sense to them but will look awful in a lawsuit can still be a problem to them, and as you keep saying, the labs weren't needed. This is a case where ordering unnecessary labs is NOT "defensive" medicine.

It creates a "gotcha." In fact, if abnormal labs had not resulted so late, I wonder if it's possible that the patient and med mal attorney would not have even seen an obvious avenue of attack and filed. It's possible they may not have. Easier to sell a narrative this was unavoidable and defend not ordering the labs.

The heparin gtt and nursing cost was cheaper in hindsight.

One thing that also made this case different was considering how you would reverse or treat for a bleed. One lesson learned, if they have Raynaud's pressors may be more problematic. So you may need to take greater care with bleeding risk, avoiding a bleed, or trying harder to treat without pressors.

So if you were on the jury and patient was renally intact with lovenox ordered you would agree malpractice occurred because anti xa was ordered but not resulted?

 

[Crayola227]

So if you were on the jury and patient was renally intact with lovenox ordered you would agree malpractice occurred because anti xa was ordered but not resulted?

I'm not a layperson. We're also missing a number of facts. But given how much more catastrophic a bleed is to manage in this particular patient because of the effect pressors can have in Raynaud's, it does sounds like ac was overly aggressive. Perhaps they should have waited a day to restart. Perhaps they should have used a heparin gtt.

As you've posed the question, I would lean to no, but I am troubled by how many with a heme background have said they would order a test, that they may have done something different or used heparin gtt.

Maybe that's the point here. This was not a patient to fly blind on because of what a bleed would result in.

 

[whoknows2012]

So to be clear if you had been consulting on this case in a community hospital you would tell your medical team that lovenox in a renally intact patient is malpractice without an anti xa level within a few hours of initiation? So does this apply to every indication for lovenox or just people with apls?

Based on what I’ve been saying it’s unreasonable to make the above conclusion from my posts. We’re all trying to work backwards with incomplete information. The expert witness was not providing “expert” analysis as routine anti-xa level monitoring is not the standard of care. In my posts I’m weighing in as a hematologist about things I may have done differently, though ultimately this doc did not violate what would have been the standard of care so long as risk benefit discussion was had, and renal fxn was intact.

Saying that he got burned for sending an anti xa level and not having a result (and offering alternatives to having to wait for a send out ie potential hep gtt) is not the same thing as saying his actions were malpractice which I don’t believe they were.

 

[chessknt]

Based on what I’ve been saying it’s unreasonable to make the above conclusion from my posts. We’re all trying to work backwards with incomplete information. The expert witness was not providing “expert” analysis as routine anti-xa level monitoring is not the standard of care. In my posts I’m weighing in as a hematologist about things I may have done differently, though ultimately this doc did not violate what would have been the standard of care so long as risk benefit discussion was had, and renal fxn was intact.

Saying that he got burned for sending an anti xa level and not having a result (and offering alternatives to having to wait for a send out ie potential hep gtt) is not the same thing as saying his actions were malpractice which I don’t believe they were.

I agree and that has been my point--the expert witness testimony looks like it was written by a hack trying to arrive to a pre-conceived notion. If this was up for a quality review I doubt anyone on the committee would have given this a red flag that would trigger privilege review/suspension because honestly there was not an egregious error made. There are some different choices that could have been made but that applies to literally every case in retrospect--the standard we are held to is "was this a major practice deviation?" and, assuming renal function is intact, I would absolutely argue it is not.

For malpractice to be met there has to be a breach of duty to the patient which in medicine has been interpreted to mean a deviation from the favorite legal phrase 'standard of care.' The problem is that the 'standard of care' is murky in this case because it is an uncommon condition and different ways to go about it that lead to the same outcome. It is like an insulin bolus + drip vs. q1-2h sq insulin vs. drip only in DKA--each has their own risks that can cause harm but all achieve the same outcome. If something bad happens you just point to whichever one wasn't used and pretend that was the standard of care and that the outcome wouldn't have happened if that had been done which, in this case, is total bull****.

 

[Chemist0157]

Why do you keep emphasizing renally intact? What evidence do you have that a patient presenting with concern for lupus nephritis necessitating biopsy despite a serious coagulopathy would have been renally intact? Is that common?

One can definitely have active lupus nephritis but stable GFR over 30 which would not necessitate an adjustment to Lovenox dosing. Active urinary sediment may have been enough to prompt kidney biopsy though I would assume there was some rise in creatinine. Again, unfortunately, those details are not readily available in the case, but I suspect they would have a higher threshold to biopsy this lady and not just do it because there were 4 RBCs on HPF on urine microscopy.

 

[collegestud2013]

It is nuts to see cases like this settle for 11 figures. Was there an issue with not checking an anti-xa? Maybe I guess but she still had a dangerous condition that needed anticoagulation and one of the risks of anticoagulation is bleeding. You bet your ass if they hadn't anticoagulated her or only started her AC off low and had a PE or arterial embolus there would have been a lawsuit there as well.

I start people on therapeutic lovenox all the time and dont check anti-xa levels for several days because it isn't accurate to check it immediately and usually only in really fat people where I am worried about under-dosing on accident. She had underlying medical conditions that basically made any form of critical illness high risk--that isn't malpractice that is just bad luck. Blaming the vasopressors that were needed to save her life for the loss of her fingers is accurate but also moot--she was dying so what was the alternative according to the hematologist? Would the settlement have been a lot less if she hadnt lost the fingers (again due to her underlying medical disease, not mismanagement)--I am going to guess yes.

The hospital offer says $ 12 million, so actually 8 figures. But I also agree that $12 million is nuts. All the more reason for more tort reform in many states, and maybe even at the federal level. Many states have caps on non-economic damages but if I remember correctly Colorado is the only state right now with an umbrella cap (set at $ 1 million per case for both economic and non-economic damages per case) which is much more reasonable. More states should set similar caps like this, and this would undoubtedly reduce malpractice insurance costs for physicians and would not lead to offers to settle for 8 figures.

Also agree that I rarely check factor Xa levels after starting Lovenox so I don't think that's the routine standard of care in the first place for the majority of patients (unlike someone on a heparin GTT where check PTTs Q4-6H is pretty standard). And if the patient's complicated case made checking factor Xa levels the standard of care, its not the physician's fault as long as the tests were properly ordered. When it comes to lab tests the physicians are only responsible for ordering the test; if it doesn't get drawn or sent off that may be nurse or phlebotomists fault (which in those cases it effectively becomes the hospital's liability).

 

[collegestud2013]

Yes, and I'm saying that sort of lazy ordering can open you up to a lawsuit. Physicians doing things that make sense to them but will look awful in a lawsuit can still be a problem to them, and as you keep saying, the labs weren't needed. This is a case where ordering unnecessary labs is NOT "defensive" medicine.

It creates a "gotcha." In fact, if abnormal labs had not resulted so late, I wonder if it's possible that the patient and med mal attorney would not have even seen an obvious avenue of attack and filed. It's possible they may not have. Easier to sell a narrative this was unavoidable and defend not ordering the labs.

The heparin gtt and nursing cost was cheaper in hindsight.

One thing that also made this case different was considering how you would reverse or treat for a bleed. One lesson learned, if they have Raynaud's pressors may be more problematic. So you may need to take greater care with bleeding risk, avoiding a bleed, or trying harder to treat without pressors.

In cases involving ordering labs, physicians are only legally responsible for placing the appropriate order in the EMR. They're not legally responsible for getting the labs drawn or processed. In this case the factor Xa WAS ordered and drawn. While you could argue that the hospital may be at fault in this case for not having the capability to return factor Xa levels in a timely manner, the physicians shouldn't settle so easily

The plaintiff probably demanded $1 million from each physician because they probably checked the maximum malpractice coverage the physicians were carrying and $1million per case is a common coverage).

 

[Crayola227]

The hospital offer says $ 12 million, so actually 8 figures. But I also agree that $12 million is nuts. All the more reason for more tort reform in many states, and maybe even at the federal level. Many states have caps on non-economic damages but if I remember correctly Colorado is the only state right now with an umbrella cap (set at $ 1 million per case for both economic and non-economic damages per case) which is much more reasonable. More states should set similar caps like this, and this would undoubtedly reduce malpractice insurance costs for physicians and would not lead to offers to settle for 8 figures.

Also agree that I rarely check factor Xa levels after starting Lovenox so I don't think that's the routine standard of care in the first place for the majority of patients (unlike someone on a heparin GTT where check PTTs Q4-6H is pretty standard). And if the patient's complicated case made checking factor Xa levels the standard of care, its not the physician's fault as long as the tests were properly ordered. When it comes to lab tests the physicians are only responsible for ordering the test; if it doesn't get drawn or sent off that may be nurse or phlebotomists fault (which in those cases it effectively becomes the hospital's liability).

A lot of this is untrue.

One, if we really want malpractice/tort reform, we need to better the social safety net. This is the trade off seen in other countries. Our malpractice/tort system takes the place of it. This woman may now be relegated to say SSI capped at $798 a month in income. No wonder people sue.

Also, people keep talking about how they don't check factor Xa levels after starting lovenox without noting that this was a case complicated enough to consult heme, and after the consultation these levels were to be drawn q6. We've already noted all the other things we don't know about this particular case to know exactly why this was.

Also, if you don't get labs you need on time to effectively manage the patient, from a malpractice POV you don't get to just shrug your shoulders. If the lack of results affects management, then you are expected to note the lack of labs and change accordingly, or explain why you are continuing therapy without the labs. You would also be expected to show that you attempted to do something about it if it matters (a note that you called someone about the delay, tried to get it redrawn or expedited or some such).

If the documentation effectively amounts to it looking like you didn't notice, didn't care, didn't adjust or take it into account, and did nothing, don't expect it to be a good defense in court.

 

[Crayola227]

In cases involving ordering labs, physicians are only legally responsible for placing the appropriate order in the EMR. They're not legally responsible for getting the labs drawn or processed. In this case the factor Xa WAS ordered and drawn. While you could argue that the hospital may be at fault in this case for not having the capability to return factor Xa levels in a timely manner, the physicians shouldn't settle so easily

The plaintiff probably demanded $1 million from each physician because they probably checked the maximum malpractice coverage the physicians were carrying and $1million per case is a common coverage).

No, this is a misperception about labs.

The expectation is that labs are ordered for a purpose for patient management. You need to explain in your note why you are taking the action you are taking without the labs, essentially risk assessment and pro/con of therapy without the lab vs the alternative.

We initiate therapy all the time while waiting for labs, and this is the justification. When the results are not obtained in a timely fashion, you need to update justifying why you are continuing to fly blind without labs, or what steps you are going to take, be it hold the course, order different therapy or order different labs.

Otherwise it looks like you made an omission.

 

[Nephro critical care]

I don’t order anti-Xa levels for Lovenox at one of the smaller hospitals I work in. Its not going to come back in a timely fashion and its not worth my time to spend 1/2 an hour waiting on a phone call with a Quest diagnostic representative.
I wouldn’t start AC on a post kidney biopsy for a few days ; I have seen significant bleeding when AC is started even 3-4 days after a biopsy. If I had to start AC I would do a lower dose heparin protocol without a bolus and not increase unless Hgb was stable for a couple of days.

 

[Crayola227]

I don’t order anti-Xa levels for Lovenox at one of the smaller hospitals I work in. Its not going to come back in a timely fashion and its not worth my time to spend 1/2 an hour waiting on a phone call with a Quest diagnostic representative.
I wouldn’t start AC on a post kidney biopsy for a few days ; I have seen significant bleeding when AC is started even 3-4 days after a biopsy. If I had to start AC I would do a lower dose heparin protocol without a bolus and not increase unless Hgb was stable for a couple of days.

Well with a name like nephro critical care I'm going to take your word about kidney biopsies, bleeds, and ac

 

[Nephro critical care]

Well with a name like nephro critical care I'm going to take your word about kidney biopsies, bleeds, and ac

My fellowship project was on complications after kidney biopsy. After reviewing all the cases with complications I developed much more respect for the kidney’s ability to bleed. It’s quite bad practice to start AC 24 hours after a kidney biopsy.

 

[NotAProgDirector]

With potential lupus nephritis, APLS, and her other comorbidities, the risk of a bad outcome was very high no matter what they did.

Although anticoagulating her the eve after her biopsy seems risky, it really depends on her prior APLS. APLS tends to cause arterial clots. Let's say she had a history of strokes, some occuring when her anticoag was low or had been held? I'd very much want to restart that evening.

I have seen enough renal biopsies go bad that they terrify me. The kidneys get a ridic % of total blood flow, so it's not a surprise they bleed like crazy. I wonder if anyone has considered doing renal biopsies internally -- snake a catheter up the renal vein, and biopsy from there, much like a transjugular liver biopsy.

 

[DoctwoB]

Kidney surgeon here. Sure AC probably could have been managed better but the real fault is Fing someone up over a kidney bleed that just needed some blood and maybe embolization if not improving.

The real error is seeing hypotension after a kidney procedure/biopsy and not having a differential of bleeding, bleeding, bleeding, bleeding, bleeding, bleeding, infection, MI/massive PE. Especially with AC involved. I get sometimes you need some pressors to buy you time to get the blood on board, but if you’re necrosing fingers you’re talking high dose pressors for a while. A cooler of O negative would have solved this problem. Most kidney bleeds will even stop on their own, gotta love the retroperioneum being an enclosed poorly dispensable space

 

[chessknt]

Kidney surgeon here. Sure AC probably could have been managed better but the real fault is Fing someone up over a kidney bleed that just needed some blood and maybe embolization if not improving.

The real error is seeing hypotension after a kidney procedure/biopsy and not having a differential of bleeding, bleeding, bleeding, bleeding, bleeding, bleeding, infection, MI/massive PE. Especially with AC involved. I get sometimes you need some pressors to buy you time to get the blood on board, but if you’re necrosing fingers you’re talking high dose pressors for a while. A cooler of O negative would have solved this problem. Most kidney bleeds will even stop on their own, gotta love the retroperioneum being an enclosed poorly dispensable space

As a kidney surgeon what has your experience been in resuscitating people with underlying cardiomyopathies? Do you typically see hemorrhagic shock days after a biopsy? How many cases of TACO or lupus myocarditis or anaphylaxis have you managed in the ICU? Throwing a cooler of blood in to someone has its own risks and not every critically ill person after a biopsy is there because they are bleeding. It isn't an error to pursue a workup before giving an irreversible treatment to somebody.

Now it is totally possible the intensivist ****ed up but the testimony available does not go over this at all. If an echo showed an underfilled LV/collapsed IVC hyperdynamic heart and pressors were still be given then yes that is a huge mistake. If hb was being used as the sole determinant of a bleed that is a huge mistake. If someone is put on pressors (especially low-moderate dose) for a few hours while investigating a cause that is not malpractice. If they had dumped 12 units of uncrossmatched blood/FFP + 2 units of platelets calcium and cryo in to the patient without trying pressors without a 100% certain diagnosis only to find out it was lupus myocarditis and they had a transfusion reaction or TACO and died that would have been malpractice.

 

[Chemist0157]

With potential lupus nephritis, APLS, and her other comorbidities, the risk of a bad outcome was very high no matter what they did.

Although anticoagulating her the eve after her biopsy seems risky, it really depends on her prior APLS. APLS tends to cause arterial clots. Let's say she had a history of strokes, some occuring when her anticoag was low or had been held? I'd very much want to restart that evening.

I have seen enough renal biopsies go bad that they terrify me. The kidneys get a ridic % of total blood flow, so it's not a surprise they bleed like crazy. I wonder if anyone has considered doing renal biopsies internally -- snake a catheter up the renal vein, and biopsy from there, much like a transjugular liver biopsy.

That approach comes up rarely but depends on having someone who is familiar with it.

I still just find it difficult to completely discount risk of thrombosis in this case. I typically have people hold their anticoagulation 1-2 days after day of biopsy. But it depends on the patient. All comers the risk is 1% of bleeding complications, but different people are different. I can think of people who bled who should have been low risk. I can think of people with a fib who had CVA while off their warfarin for just that short of time. It just happens…that’s why we tend to be picky with who gets a biopsy…

I think the medical team can make a case that risk of thrombosis was higher than risk of bleeding depending on the patient’s history. We just don’t have a lot of details.

 

[Crayola227]

As a kidney surgeon what has your experience been in resuscitating people with underlying cardiomyopathies? Do you typically see hemorrhagic shock days after a biopsy? How many cases of TACO or lupus myocarditis or anaphylaxis have you managed in the ICU? Throwing a cooler of blood in to someone has its own risks and not every critically ill person after a biopsy is there because they are bleeding. It isn't an error to pursue a workup before giving an irreversible treatment to somebody.

Now it is totally possible the intensivist ****ed up but the testimony available does not go over this at all. If an echo showed an underfilled LV/collapsed IVC hyperdynamic heart and pressors were still be given then yes that is a huge mistake. If hb was being used as the sole determinant of a bleed that is a huge mistake. If someone is put on pressors (especially low-moderate dose) for a few hours while investigating a cause that is not malpractice. If they had dumped 12 units of uncrossmatched blood/FFP + 2 units of platelets calcium and cryo in to the patient without trying pressors without a 100% certain diagnosis only to find out it was lupus myocarditis and they had a transfusion reaction or TACO and died that would have been malpractice.

But this patient was imaged showing the hematoma and taken back for embolization BEFORE being transferred to the ICU. Are you really sure she wasn't there for, oh I don't know, a *bleed*?" And as someone pointed out, we're probably not talking about someone who waa given pressors for long enough to effectively rule out quickly most of the differentials that have been given, like infection, MI, PE.

Really sounds like she wasn't properly resuscitated.

I'm willing to bet the Raynaud's was not being treated as an active hospitalization issue, and was effectively forgotten about in the management and she was stuck on pressors for many hours to days essentially by habit, until oopsies her fingers fell off reminding everyone. And I wouldn't be surprised if no one noticed on PE some of the early changes in her fingers.

Things like this get missed all the time. Most of the time it ends up OK, but sometimes it doesn't and when it doesn't, that's real bad.

 

[Crayola227]

That approach comes up rarely but depends on having someone who is familiar with it.

I still just find it difficult to completely discount risk of thrombosis in this case. I typically have people hold their anticoagulation 1-2 days after day of biopsy. But it depends on the patient. All comers the risk is 1% of bleeding complications, but different people are different. I can think of people who bled who should have been low risk. I can think of people with a fib who had CVA while off their warfarin for just that short of time. It just happens…that’s why we tend to be picky with who gets a biopsy…

I think the medical team can make a case that risk of thrombosis was higher than risk of bleeding depending on the patient’s history. We just don’t have a lot of details.

We don't have enough info, because it's also possible that it wasn't just the ac that was the issue, but also just the response after the fact of the bleed. How the bleed itself was managed matters, not just that she was ac'd and how and how it was monitored.

 

[chessknt]

But this patient was imaged showing the hematoma and taken back for embolization BEFORE being transferred to the ICU. Are you really sure she wasn't there for, oh I don't know, a *bleed*?" And as someone pointed out, we're probably not talking about someone who waa given pressors for long enough to effectively rule out quickly most of the differentials that have been given, like infection, MI, PE.

Really sounds like she wasn't properly resuscitated.

I'm willing to bet the Raynaud's was not being treated as an active hospitalization issue, and was effectively forgotten about in the management and she was stuck on pressors for many hours to days essentially by habit, until oopsies her fingers fell off reminding everyone. And I wouldn't be surprised if no one noticed on PE some of the early changes in her fingers.

Things like this get missed all the time. Most of the time it ends up OK, but sometimes it doesn't and when it doesn't, that's real bad.

Based on the info we have so far I think we can come to the conclusion that the hematology expert witness is full of **** with his standard of care anti xa nonsense.

We don’t know the details of the resuscitation but I stand by the fact that you can’t just pour huge amounts of blood in to a shock patient with a 2d post op renal capsule hematoma as the diagnosis and think that is good medicine without something else supporting the diagnosis (pocus, exam, hb not incrementing etc).

 

[DoctwoB]

Based on the info we have so far I think we can come to the conclusion that the hematology expert witness is full of **** with his standard of care anti xa nonsense.

We don’t know the details of the resuscitation but I stand by the fact that you can’t just pour huge amounts of blood in to a shock patient with a 2d post op renal capsule hematoma as the diagnosis and think that is good medicine without something else supporting the diagnosis (pocus, exam, hb not incrementing etc).

Look we weren’t there. Weird things happen in medicine. But renal bleeding usually isn’t subtle. H/h drops (usually). Flank hurts, as it’s pretty impossible to drop a liter or two of a caustic substance into your retroperitoneum and not have pain. Maybe hematuria. Certainly signs of volume depletion on exam, US, A-line, pick your preferred method. Hematoma on imaging. Keep in mind to drop your pressure typically you need to lose 30%, or 1.5 liters. That’s a 20x15x10 hematoma. Not something subtle. Given sick patient, maybe it’s half that to drop their pressure. Still a big ass hematoma. You’re saying that a patient can essentially exsanguinate (which is what would have happened if not in a setting with pressors immediately available) after a procedure that has a bleeding risk in the setting of AC use and it’s ok if a doc doesn’t diagnose it.

You know how it goes in practice. Nurse calls or there is a code and patient is tachy and hypotensive. Undifferentiated at that point. You bolus fluids, get a transient response, maybe start some pressors, peripherally if needed while you get more fluids in, send labs and cultures, get the patient lined up if they’re not already.

At this point you probably get a story of flank pain if patient is talking. Usually fullness, tenderness, and/or bruising on exam. Depending on rate of bleed you probably (but not always) see the drop in crit which makes it obvious. If somehow, your exam and labs don’t give you an answer, a scan or pocus will and you treat appropriately. So no, you’re not running up to an undifferentiated patient and slamming them with product. But everything I mentioned should take about 30 minutes, maybe 60 if scanning. That’s not what necrosed her fingers. And if you’re smart, you had bleeding high on your differential and were getting the blood ready during this time.

 

[chessknt]

You’re saying that a patient can essentially exsanguinate (which is what would have happened if not in a setting with pressors immediately available) after a procedure that has a bleeding risk in the setting of AC use and it’s ok if a doc doesn’t diagnose it.

It wasn't immediately after the procedure though, it was 3 days afterwards. I am saying it is not just ok but rather standard of care to have a differential and work through it before activating 2x massive transfusion protocol in an undifferentiated scenario. We dont know how much blood was given before pressors were used--if it was 2 units and still hypotensive is that ok? 6? 12? At what point do you wonder if you are wrong? And you mentioned uncrossmatched blood, that is typically reserved for highly emergent bleeds--you would use that in this scenario?

As it was happening in real time I doubt it was as clear as you make it sound like--3 days is enough time to develop an infection if there was a sterility issue or if the lupus was under poor control there are other potential things that exist on the differential that blood would make worse.

 

[CaliDent383]

What are people even talking about in this thread? The 10a level taking 3 days to come back is almost irrelevant and the least of the issues.

I think it seems pretty obvious heparin gtt should have been started instead of lovenox given the high bleeding risk post-op and ability to stop the drip vs. trying to reverse lovenox with protamine or andexanet alpha in an APLS patient. In addition, if someone has AKI bad enough to require kidney biopsy it's very likely their CrCl is likely <30 and not completely stable making lovenox a malpractice-worthy choice.

Starting anticoagulation shortly after biopsy is prudent given the very high clotting risk with APLS, it just should have been done with heparin. Some APLS patients can be monitored with ptt if not significantly elevated at baseline. Monitoring of heparin in most APLS patients would require anti-10a monitoring which would have been delayed, but at least you can turn it off and you're less likely to get supratheraputic in AKI compared to lovenox, both features that would have made the poor outcome much less likely.

An intensivist using pressors in addition to transfusions is standard of care in hemorrhagic shock, nobody is going to allow someone to sit there with MAPs in the 40's or 50's despite ongoing transfusions.

 

[Crayola227]

What are people even talking about in this thread? The 10a level taking 3 days to come back is almost irrelevant and the least of the issues.

I think it seems pretty obvious heparin gtt should have been started instead of lovenox given the high bleeding risk post-op and ability to stop the drip vs. trying to reverse lovenox with protamine or andexanet alpha in an APLS patient. In addition, if someone has AKI bad enough to require kidney biopsy it's very likely their CrCl is likely
Starting anticoagulation shortly after biopsy is prudent given the very high clotting risk with APLS, it just should have been done with heparin. Some APLS patients can be monitored with ptt if not significantly elevated at baseline. Monitoring of heparin in most APLS patients would require anti-10a monitoring which would have been delayed, but at least you can turn it off and you're less likely to get supratheraputic in AKI compared to lovenox, both features that would have made the poor outcome much less likely.

An intensivist using pressors in addition to transfusions is standard of care in hemorrhagic shock, nobody is going to allow someone to sit there with MAPs in the 40's or 50's despite ongoing transfusions.

As said before, one does also have to wonder how long pressors were used for and if a good case can be made they were used too long or not weaned appropriately.

A lot of malpractice cases as well, instead of being one big huge obvious error, end up being a small sequence of smaller more questionable/debatable decisions, and I think that increases the likelihood of not being able to defend it all terribly well in front of a jury.

If nothing else, this thread shows there is some doubt that all the right choices were made.

 

[turkeyjerky]

As said before, one does also have to wonder how long pressors were used for and if a good case can be made they were used too long or not weaned appropriately.

A lot of malpractice cases as well, instead of being one big huge obvious error, end up being a small sequence of smaller more questionable/debatable decisions, and I think that increases the likelihood of not being able to defend it all terribly well in front of a jury.

If nothing else, this thread shows there is some doubt that all the right choices were made.

I think from a clinical perspective, this is very important as well as underappreciated. It's not always inappropriate to start vasopressors in hemorrhagic shock (in fact, there's emerging evidence from trauma literature that they, namely vasopressin, actually might be beneficial), but it needs to be done appropriately. After all, unless you're in the trauma bay or the OR, you likely don't have a bunch of product just sitting there waiting to be infused.

Logistically, however, it oftentimes ends up being very difficult to get the pressors weaned off. Unless you're an anesthesiologist, most of us are not actively adjusting the infusion pump, but rather giving the nurse a vague recommendation to wean as tolerated. In addition, you've taken away a resuscitation end point, in that the BP is now uninterpretable.

On a semi-related note. What're peoples thoughts about vasopressin in the setting of DI? I would think that being able to decrease the dose of NE might be a worth goal, however in the past vaso was always blamed (although my understanding is that this was in the setting of truly massive doses that are no longer used). Obviously, I think med-mal wise, you're f'd either way.