What would you do?

[Chronic Student]

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So here is the scoop.

We have a kid in his mid 20's with CML who is in blast crisis. His INR has been anywhere from 2.2 to 1.6.

He has a large, chronic frontotemporal subdural with 4 mm of midline shift. No neuro deficits and his only real symptom is a frontal, moderately severe HA.

We will almost certainly be able to drain it through a couple of burrholes, but we want his PT corrected before we take him to the OR.

We have been waiting to operate on this guy for three weeks. IM is dragging their feet and can't possibly give him more than 3 units of FFP q24 hours and the occasional dose of vitamin K (sarcasm intended).

We have told them that we would, ideally, like for his INR to be 1.2 before we take him to surgery, but we would even take him if it was 1.3 or 1.4. We have been going back and forth for quite a while and our concern is that the kid is eventually going to crumple.

They want us to take him to surgery as is and we have told them in no uncertain terms, HELL NO! I mean we operate on him as is and he re-bleeds and we have exposed him to risks of surgery, etc. They even got miffed with us and called for a second NS consult and they said the same exact thing.

They have done some mixing studies and they came out partially corrected. OK, so he has some kind of circulating anticoagulant and I understand they may think that more FFP won't help. However, they have not tried any more than 3 Units of FFP, ever.

Does any one have any comments, suggestions, differing views, etc?

-Mike

 

[Debridement]

So here is the scoop.

We have a kid in his mid 20's with CML who is in blast crisis. His INR has been anywhere from 2.2 to 1.6.

He has a large, chronic frontotemporal subdural with 4 mm of midline shift. No neuro deficits and his only real symptom is a frontal, moderately severe HA.

We will almost certainly be able to drain it through a couple of burrholes, but we want his PT corrected before we take him to the OR.

We have been waiting to operate on this guy for three weeks. IM is dragging their feet and can't possibly give him more than 3 units of FFP q24 hours and the occasional dose of vitamin K (sarcasm intended).

We have told them that we would, ideally, like for his INR to be 1.2 before we take him to surgery, but we would even take him if it was 1.3 or 1.4. We have been going back and forth for quite a while and our concern is that the kid is eventually going to crumple.

They want us to take him to surgery as is and we have told them in no uncertain terms, HELL NO! I mean we operate on him as is and he re-bleeds and we have exposed him to risks of surgery, etc. They even got miffed with us and called for a second NS consult and they said the same exact thing.

They have done some mixing studies and they came out partially corrected. OK, so he has some kind of circulating anticoagulant and I understand they may think that more FFP won't help. However, they have not tried any more than 3 Units of FFP, ever.

Does any one have any comments, suggestions, differing views, etc?

-Mike

Mike,

Tough case. Sounds like this kid is sick.

From the surgical management, I see it this way. CC: "HA c no neuro deficits". Liklihood of progression: depends on coagulopathy. Surgical risk: depends on coagulopathy

It's tough to take someone whose only complaint is pain to the OR for a risky procedure, albeit a prophylactic one. I don't know the liklihood of progression, but I would bet that it is directly related to his coagulopathy (which is the same thing making his trip to the OR risky).

I see it like this: 1) Do nothing as sx are only HA now. If he has a change in mental status, your hand is forced, and the status of the coagulopathy becomes irrelevant. 2) When INR is corrected, prophylactic and therapudic treatment is warranted. 3) Don't take him for HA sx only when INR is 1.4+ since you are exposing him to a lot of risk for little gain.

On a side note, remember that those CT guys do tons of cases with the pt anticoagulated. Anti-coagluated does not eliminate the ability to achieve hemostasis, it just changes the timing and liklihood.

Let me know what you guys did.

Tough case,

DB out

 

[Chronic Student]

I hear what your saying, but there are a couple of issues that make it difficult.

1. He can crump at any time and then you have a true emergency and his INR sucks and then what do you do with him.

2. We take people to the OR with only a headache all the time, that is one of the common presentations of a chronic subdural hematoma.

3. In neuro, the idea is to get to the things before they are a problem.

4. I also have to disagree with your CT analogy for a couple of reasons. The cranial cavity is a closed space and increased bleeding leads to dire consequences and can't just be treated with pressors and fluids. Secondly, access to the bleeding is greatly restricted for the obvious reasons and you may not be able to get to that bleeding. In short, Neuro is a very different animal from most surgical specialities.

In the end, he already has 4mm of midline shift. So, with your management we would wait for the midline shift to worsen, wait for the nurse to pick it up, then call us, then wait for us to drive 30 minutes to the hospital in the other city and then get him to the OR and get exposure. The end result would be that he is already herniated and is left with severe neurologic deficit, if not dead.

Not a good outcome.

-Mike

 

[UTSouthwestern]

I hear what your saying, but there are a couple of issues that make it difficult.

1. He can crump at any time and then you have a true emergency and his INR sucks and then what do you do with him.

2. We take people to the OR with only a headache all the time, that is one of the common presentations of a chronic subdural hematoma.

3. In neuro, the idea is to get to the things before they are a problem.

4. I also have to disagree with your CT analogy for a couple of reasons. The cranial cavity is a closed space and increased bleeding leads to dire consequences and can't just be treated with pressors and fluids. Secondly, access to the bleeding is greatly restricted for the obvious reasons and you may not be able to get to that bleeding. In short, Neuro is a very different animal from most surgical specialities.

In the end, he already has 4mm of midline shift. So, with your management we would wait for the midline shift to worsen, wait for the nurse to pick it up, then call us, then wait for us to drive 30 minutes to the hospital in the other city and then get him to the OR and get exposure. The end result would be that he is already herniated and is left with severe neurologic deficit, if not dead.

Not a good outcome.

-Mike

Take him to preop holding and give FFP there until the INR corrects. Draw a TEG preop with platelet mapping, take him to the OR if his platelets show adequate function and do the case with strict attention to intraop hemostasis. Postoperatively, recheck his INR and TEG and hand him back to IM after 6 hours of adequate clotting time and no evidence of rebleeding.

I have to assume you are in an academic program where the modus is delay, delay, delay until an act of God corrects this patient's coagulopathy.

If IM is that focused on a possible circulating anticoagulant, then treat it empirically (steroids, plasmapheresis, whatever) and get moving.

 

[Debridement]

I hear what your saying, but there are a couple of issues that make it difficult.

1. He can crump at any time and then you have a true emergency and his INR sucks and then what do you do with him.

2. We take people to the OR with only a headache all the time, that is one of the common presentations of a chronic subdural hematoma.

3. In neuro, the idea is to get to the things before they are a problem.

4. I also have to disagree with your CT analogy for a couple of reasons. The cranial cavity is a closed space and increased bleeding leads to dire consequences and can't just be treated with pressors and fluids. Secondly, access to the bleeding is greatly restricted for the obvious reasons and you may not be able to get to that bleeding. In short, Neuro is a very different animal from most surgical specialities.

In the end, he already has 4mm of midline shift. So, with your management we would wait for the midline shift to worsen, wait for the nurse to pick it up, then call us, then wait for us to drive 30 minutes to the hospital in the other city and then get him to the OR and get exposure. The end result would be that he is already herniated and is left with severe neurologic deficit, if not dead.

Not a good outcome.

-Mike

How long has he had this subdural? If he's had it 2-3 weeks, at home with his coagulopathy at it's worst, I would think that in house, his coagulopathy is better (than it was at home) and his liklihood of progressing the bleed would be lower than it was over the last 2-3 weeks. Is this not correct?

As far as #2 goes, this is usually in pts without an underlying coagulopathy or other extremely high surgery risk, yes? Grandma who takes coumadin for afib who comes in with a sub-dural and a supratherapudic INR has a correctable condition and is in a different boat than this kid.

It sounds like you and IM have tried to correct this coagulopathy and have failed, due to his CML and that acheiving correction today is not on the table. That is the the assumtion upon which I would base my decision tree.

We'd all agree if the coagulopathy is corrected, there is no dilemma.

Were they able to correct it with more aggressive FFP?

For #3, you don't want the treatment to be worse than the disease, and of now, he is not herniated and has not progressed his bleed.

Is he in a unit setting? If he's in a unit, I would feel a bit better with q1h neuro checks, and if hemo/onc was going to send him to a floor, I would really think hard about taking him to the OR and getting him in the neuro unit. I agree with your concern about nursing, driving 30 minutes, etc if he is on a floor. People die on the floor....

Let us know what was decided and how he does,


DB