[HSF] Too scared to touch.....

[erdinç naseri]

Michael,
If we summarize the patient's medical condition:
1.Carcinomatosis  of peritonium with no known primary for the last couple of 
years:this in itself is very interesting because this type of patient 
doesn't live that much.
2.Cirrhosis of at least child class B
3.CRF
4.anemia .most probably of chronic disease type.
5:AVM of CNS
and  most probably a lot of other minor and major conditions.If the patient 
needs an orthopedic surgery it would be in the benefit of the patient to 
proceed with that operation and accept her as a high risk anestesia case and 
leave her heart untouched.( agree with ani)
erdinc

>From: Michael Firstenberg <msfirst at gmail.com>
>Reply-To: OpenHeart-L at lists.hsforum.com
>To: OpenHeart-L at lists.hsforum.com
>Subject: [HSF] Too scared to touch.....
>Date: Sat, 28 Apr 2007 10:36:50 -0400
>
>Would anyone do anything different?
>
>52 year/old, multiple medical problems (poorly controlled diabetes,  
>hypertension, high lipids of course - and dont forget obese).  Known  brain 
>AVM, cryptogenic cirrhosis with history of varices/bleeding/ blakemore tube 
>(the works, but nothing recent and LFTs/proteins not  too bad) - treated 
>with mesocaval shunt for portal vein thrombosis in  1999.  Splenic 
>embolization also.  Chronic anemia and renal  insufficiency.  CT scan of 
>abdomen "suggests carcinomatosis" -  slightly worse over past "couple of 
>years" - but no primary (CA125  elevated  to ~60 baseline in our hospital 
>0-40, already had TAH-BSO  years ago).  About six months ago, fell and got 
>a "hairline" fracture  of left hip - no intervention, but developed a DVT 
>in right leg.   Recently, fell again (may have been near syncope) and broke 
>right  ankle in several places.  Admitted to outside hospital after fall,  
>hypotensive, found to have a troponin of ~20 with a moderate RV  infarct.  
>Taken to cath lab for PCI (BMS to occluded right -  interesting as she was 
>on coumadin) - opened up,  but also has  significant LAD/Cx disease.  Good 
>targets.  Cardiology asking for off- pump LIMA-LAD and they will do a 
>protected left main stent.   Anesthesia and Ortho doesnt want to fix her 
>ankle until her heart is  taken care of.
>
>Would anyone operate?
>
>Cardiology somewhat understanding of our reluctance to "take the high  
>potential operative mortality hit" and in fact they are not sure they  even 
>want to "take the PCI hit".  To be honest, we all want to try  and help 
>(not sure of the long term benefit as no one has any idea of  her long-term 
>prognosis), but no one wants to have a potential CABG  mortality.
>
>Hal - can I send her to you?
>
>
>-michael
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