Would you do RF in this patient?

[Timeoutofmind]

Would you do it? My concern is if he will have a bleeding issue.

Frail, 81yo and ill with metastatic carcinoid cancer. No active tx. His diarrhea remains controlled with monthly octreotide injections
PLT 47
On warfarin

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[willabeast]

Would you do it? My concern is if he will have a bleeding issue.

Frail, 81yo and ill with metastatic carcinoid cancer. No active tx. His diarrhea remains controlled with monthly octreotide injections
PLT 47
On warfarin

Perfect candidate for fentanyl patch, just titrate up the patch until his diarrhea is controlled. won't be a need for the RF or the octreotide on the fentanyl patch. FYI cost of octreotide one dose follows
LAR Dose (mg)

W.A.C.

Cost

Medicare

Reimbursement*

10

$1,300.64

$886.90

20

$1,493.76

$1,773.80

30

$2,007.29

$2,660.70

5

$785.05

$443.45

 

[No Pain All gain]

If you’re talking RF does that mean you already did blocks?


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[lobelsteve]

Perfect candidate for fentanyl patch, just titrate up the patch until his diarrhea is controlled. won't be a need for the RF or the octreotide on the fentanyl patch. FYI cost of octreotide one dose follows
LAR Dose (mg)

W.A.C.

Cost

Medicare

Reimbursement*

10

$1,300.64

$886.90

20

$1,493.76

$1,773.80

30

$2,007.29

$2,660.70

5

$785.05

$443.45

Not concerned about the bleeding risk. Concerned about the Fentanyl patch and increased fall risk as he gets constipated and sedated. I guess you could put a pillow over his face for a few minutes but that would not be ethical or legal. Maybe we family would do the job for you.

How about more about his pain and functional status.

 

[willabeast]

Not concerned about the bleeding risk. Concerned about the Sentinel and pack trading till he gets constipated or sedated. I guess you could put a pillow over his face for a few minutes but that would not be ethical or legal. Maybe we family would do the job for you.

I assumed Timeout knows the pharmacology and kinetics of Fentanyl patch. Maybe not everyone does? Obviously do not try a Rx option if unskilled in it's application.

 

[Timeoutofmind]

If you’re talking RF does that mean you already did blocks?


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No not yet

 

[No Pain All gain]

With 25 ga needle not unreasonable to do blocks. I would RF this patient’s medial branches after discussion about risks w pt and family


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[244913]

I'd RF- document risk/benefit. How functional is he at baseline? Would the intervention make a tangible difference is the question

 

[Orin]

What are you RFing?

I would probably just phenol/EtOH the MBB in this patient if you thought there was facetogenic pain. Less is more.

 

[Ducttape]

what exactly are you ablating?

for facetogenic pain, is there data that suggests that chemical neurolysis is better than thermal? cause I know of no such study.

 

[Orin]

what exactly are you ablating?

for facetogenic pain, is there data that suggests that chemical neurolysis is better than thermal? cause I know of no such study.

LMGTFY

Comparison of alcohol ablation with repeated thermal radiofrequency ablation in medial branch neurotomy for the treatment of recurrent thoracolumba... - PubMed - NCBI

In this scenario though, the question is more of safety/value to the patient than efficacy. This is a frail patient who is anticoagulated and has a malignancy which may be terminal.

 

[lonelobo]

there may be some bleeding outside canal, who cares

 

[Timeoutofmind]

LMGTFY

Comparison of alcohol ablation with repeated thermal radiofrequency ablation in medial branch neurotomy for the treatment of recurrent thoracolumba... - PubMed - NCBI

In this scenario though, the question is more of safety/value to the patient than efficacy. This is a frail patient who is anticoagulated and has a malignancy which may be terminal.

His cancer is not too aggressive. He walks around and mows his own lawn and everything. He’s pretty active.
I think it would definitely benefit him. Was more just a question of the coagulation

 

[Ducttape]

that study is interesting....

but it presupposes that the patients have already undergone a successful RFA before a repeat RFA or chemical ablation, so it is not completely applicable to this case. in addition, this frail patient may not have 24 months to notice a difference.

so do the initial RFA, like in the study. if it doesn't last, then, if you believe the study, do chemical ablation.

 

[DODOCSS]

ask lax

 

[Orin]

Sweet, if the KPS is solid, go for it.

Does he need an intervention though if he's doing all that at 81 with metastatic cancer?

What's the enemy of good?