Tomorrow's case

[dhb]

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53 y/o M for TURP
Alcoholic, cirrhosis Child B to C:
INR 1.47 on 4/1 but 1.9 on 3/1 aPTT 47sec Bili 9g/dl Hb 10 platlets 70.000/mm3 fibrinogen 1g/dl
PMH COPD, Tuberculosis w brain abscess 2y ago 😱 treated, testicule chopped of in january for big abscess under spinal but his coag was better then.
heart echo wnl ecg ok
exam: patient doesn't look as $hitty as his liver, icteric, heart ok lungs free some ascitis but not distending the abdomen, lower ext edema no teeth MP I
no meds at home lasix sometimes if his legs get swollen...

What's the plan? platelets are available in 1h FFP in 30min (thawed)

 

[militarymd]

lma

 

[drccw]

I'm a wimp. I would opt for a tube.

 

[urge]

You most be a CA1.

Prop, sux, tube or Prop, LMA.

 

[Planktonmd]

Yes, any flavor of general anesthesia should be fine.

 

[Jeff05]

i would give platelets and 2-4 units of FFP.

watch the sodium carefully, because he is likely hyponatremic already.

 

[jetproppilot]

lma

Ditto.

 

[dhb]

i would give platelets and 2-4 units of FFP.

watch the sodium carefully, because he is likely hyponatremic already.

anybody else gonna give some products?

patient is in the process of being cancelled for medical tune up.

 

[militarymd]

anybody else gonna give some products?

patient is in the process of being cancelled for medical tune up.

short of a liver transplant...he's not going to get much better than this...

You could argue the following:

aldactone + lasix + sodium restriction >>>>> ascites and edema
nadolol >>>>> portal pressure gradient
diet to include essential amino acids/arginine >>>>> heal liver


and for how long????

as before ....lma...

blood products as needed..or not.

 

[Planktonmd]

anybody else gonna give some products?

patient is in the process of being cancelled for medical tune up.

😕
Why?

 

[dhb]

😕
Why?

don't know hence the question patient has a bad coag, bleeding problem? i've never see someone get cut with that kind of coagulation: no liver transplant yet...

 

[fakin' the funk]

likely hyponatremic already.

Why? (curious MS3 question)

 

[Idiopathic]

i've never see someone get cut with that kind of coagulation

what

 

[Idiopathic]

Why? (curious MS3 question)

Its got to do with decreased metabolism of vasopressin and other hormones that are either improperly made or not broken down that affect the renal excretion of H2O (PGE, etc). I think also since the hearts sees a relative decrease in preload you get lots of aldosterone and ADH, which causes a net retention, but of dilute Na-solution, similar to what happens in CHF. These patients retain lots of water

 

[dhb]

what

could you elaborate?

 

[Jeff05]

he's gonna bleed without FFP or plt. or maybe he won't. i would rather MAKE SURE he doesn't bleed and give him some product.


if this guy has any significant amount of ascites he's a full stomach. no LMA here, tube. maybe he won't aspirate and everything will be just fine. but, it's not that hard to put a tube in and MAKE SURE he doesn't.

i think the safe approach would be to give product and RSI.

 

[militarymd]

he's gonna bleed without FFP or plt. or maybe he won't. i would rather MAKE SURE he doesn't bleed and give him some product.


if this guy has any significant amount of ascites he's a full stomach. no LMA here, tube. maybe he won't aspirate and everything will be just fine. but, it's not that hard to put a tube in and MAKE SURE he doesn't.

i think the safe approach would be to give product and RSI.

If you know of a special kind of ETT that prevents aspiration....please all the intensivists out there know....

I don't know of ANYWAY to "make sure" some one doesn't aspirate.

 

[Jeff05]

i agree that aspiration is possible with an ETT. but, it's much more probable with an LMA. nothing is 100%, i just go with what i understand to be the optimal clinical decision.