SVC Syndrome Clarification
Dr. Genes pointed out that while likely still the most common etiology of SVCS is cancer, the emerging etiology is Pacemaker implantation/extraction.
I didn’t find evidence that it is the clear cut most common cause, but it is possible we are heading that way.
Herscovici R, Szyper-Kravitz M, Altman A, Eshet Y, Nevo M, Agmon-Levin N, Shoenfeld Y. Superior vena cava syndrome – changing etiology in the third millennium. Lupus. 2012 Jan;21(1):93-6. doi: 10.1177/0961203311412412. Epub 2011 Aug 15.
Riley RF, Petersen SE, Ferguson JD, Bashir Y. Managing superior vena cava syndrome as a complication of pacemaker implantation: A pooled analysis of clinical practice. Pacing Clin Electrophysiol 2010; 33:420–425.
This is a correction to the Heme question #2 that I sent out over the weekend (thanks to Strayer. No matter where he is in the world, he is still keeping tabs and making sure we are keeping our knowledge up to date)
-There is no evidence to support FFP prior to diagnostic paracentesis with patients with abnormal coagulation profile, but otherwise normal (Grade 2B)
-There have been multiple studies showing the safety of paracentesis without prophylactic transfusion of blood products.
http://www.uptodate.com/contents/diagnostic-and-therapeutic-abdominal-paracentesis?source=search_result&search=paracentesis&selectedTitle=1%7E57
- Runyon BA. Paracentesis of ascitic fluid. A safe procedure. Arch Intern Med 1986; 146:2259.
- McVay PA, Toy PT. Lack of increased bleeding after paracentesis and thoracentesis in patients with mild coagulation abnormalities. Transfusion 1991; 31:164.
- Grabau CM, Crago SF, Hoff LK, et al. Performance standards for therapeutic abdominal paracentesis. Hepatology 2004; 40:484.
Patients who should not get diagnostic taps are those with evidence of:
- DIC
- Primary fibrinolysis
- Massive illeus or obstruction with significant bowel distension
*one should also avoid tapping directly into surgical scars as bowel tends to adhere to previous sites of surgery.
*if truly concerned about SBP in these populations, would empirically treat
From Guidelines on the Management of ascites in cirrhosis
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1860002/
“Complications of ascitic taps occur in up to 1% of patients (abdominal haematomas) but are rarely serious or life threatening. More serious complications such as haemoperitoneum or bowel perforation are rare (<1/1000 procedures). Paracentesis is not contraindicated in patients with an abnormal coagulation profile. The majority of patients with ascites due to cirrhosis have prolongation of the prothrombin time and some degree of thrombocytopenia. There are no data to support the use of fresh frozen plasma before paracentesis although if thrombocytopenia is severe (<40 000) most clinicians would give pooled platelets to reduce the risk of bleeding.”
