Spotlight Case June 2007. Beeline to Spine. Source and Credits. This presentation is based on June 2007 AHRQ WebM&M Spotlight Case See full article at http://webmm.ahrq.gov CME credit is available online
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Beeline to Spine
At the conclusion of this educational activity, participants should be able to:
An 83-year-old man with CAD, mild heart failure, history of repaired AAA, and prior lumbar disk disease (status post L5-S1 fusion) was scheduled for a fusion-augmentation surgery by orthopedics. Although the patient noticed a bulging mass on his abdomen a few months earlier, he did not mention it to providers. Laboratory tests sent for a voluntary medical research study showed an elevated alkaline phosphatase to nearly 800 U/L. His primary physician reviewed these lab results, but no action was taken.
The patient proceeded to surgery, where he was examined by both the anesthesiology and surgery teams. He underwent surgery in the supine position, given his history of AAA repair. The fusion augmentation was uneventful, and he was discharged home.
Davenport DL, et al. Ann Surg. 2006;243:636-644.
American Society of Anesthesiologists Web site.
See Notes for complete references.
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*Carlisle J, et al. Br J Anaesth. 2004;93:495-497.‡Smetana GW, Macpherson GS. Med Clin N Amer 2003;87:7-40.
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Geerts WH, et al. Chest. 2004;126(suppl 3):338S-400S.Bratzler DW, Hunt DR. Clin Infect Dis. 2006;43:322-330.
One week later, the patient was admitted with frank jaundice, abdominal pain, and diarrhea. Physical examination revealed a 4x4 cm, easily palpable mass protruding from his mid-abdomen. CT scan revealed a widely metastatic pancreatic cancer. There was massive tumor burden along the peritoneum and adjacent to stomach, liver, and bowels. A CA 19-9 was extremely high.
When told of his diagnosis of metastatic cancer, the patient immediately said he wished he had never undergone the surgery.
Review of the preoperative assessment by anesthesia and orthopedics revealed no mention of an epigastric mass nor of the markedly abnormal alkaline phosphatase.
Cantlay K, et al. Anaesthesia. 2006;61:234-239.
Correll DJ, et al. Anesthesiology. 2006;105:1254-1259.