PIG Meeting: 4th March 2021

Case one:

64yo male for lap high anterior resection for sigmoid polyp unresectable at colonoscopy.

PHx: HTN, dyslipidaemia, obesity BMI 33, smoker, chronic mild hyponatraemia (thought secondary to alcohol misuse)

On day of surgery:

• Identified in the bay as high risk for OSA (STOP-BANG 6, body/facial habitus highly suggestive)
• Conversion to laparotomy after failed initial anastomosis.
• Pain well controlled with multimodal analgesia (TAP catheters, ketamine intra-op, opioids, COX2i, paracetamol)
• Extended observation in PARU to ensure sedation/respiratory depression v. Analgesia favourable.
• Referred to ICU outreach for closer observation overnight.
• Nil issues arose.

Discussion:

Visual cue of the obese patient may lead to missed identification of patients at risk of OSA.

ICU outreach can provide a valuable tool for patients identified as at increased risk for an adverse perioperative outcome.

Case two:

74yo male for TAMIS resection of rectal polyp.

PHx: HTN, severe vertebrobasilar disease, BMI 34. Atrial ectopy on ECG from 18mths prior.

On day of surgery:

• Identified at time of positioning for SAB as having irregular pulse and cardiac output on arterial line (arterial line used due to severe cerebrovascular disease)
• 12 lead ECG difficult to interpret, initial showing ? Atrial ectopy, then a second trace showing atrial flutter with variable block.
• Electrolytes normal
• Corridor consultation with two anaesthetists regarding decision to proceed or cancel. Precancerous lesion (i.e. non-urgent surgery) v. Clopidogrel already withheld 7days exposing patient to stroke risk v. Poor usage of theatre time v. Patient expectations v. Already significant delays on the day due to surgical misadventure with previous patient…Decision to proceed.
• HR dropped to 40 with colonic insufflation with ~5-6 flutter waves before a ventricular complex, BP maintained, ? CHB.
• Treated with atropine, appeared to respond initially but not with a second episode.
• Pads placed in case pacing required. Isoprenaline sourced.
• Discussed with cardiology AT
  • Patient admitted to monitored bed (G3) overnight.
  • Formally diagnosed with atrial flutter.
  • Plan for commencement of Apixaban once surgeons satisfied bleeding risk passed.
  • Discharged home, plan for referral to cardiologist and for TTE, by GP.
• Could this situation have been avoided with a face-to-face consultation?
  • Physical examination and ECG in clinic would likely have identified the issue
  • ECGs can be requested (e.g. from GP) even with phone consultations in patients who meet the preop criteria.
  • Age > 50 (men), > 60 (women)
  • Cardiac disease as evidenced by history or exam
  • Presence of cardiac risk factors
  • On further questioning, this patent did actually have a history of palpitations and was awaiting investigation by the GP.
• How should this patient have been worked up prior to non-urgent surgery?
  • Check serum electrolytes
  • TFTs
  • TTE to look for structural heart disease
  • Cardiologist review for rate control, treatment of active precipitating disease processes, anticoagulation and consideration of electrical or pharmacologic cardioversion.