High risk patient, low risk procedure

garychleung

PIG Meeting: 11th March 2021

34 year old lady for hysteroscopy, endometrial biopsy and mirena

Background

  • Abnormal uterine bleeding for many years. No previous investigations.
  • Super-morbidly obese. BMI 78
  • Severe OSA. AHI 100 with >50% of sleep at saturations less than 85%
  • Admission to ICU in last few years with respiratory failure post-URTI
  • NIDDM. Good glycaemic control.
  • Severe social anxiety.

Issues

  • Declining spinal and/or light sedation. Requesting only GA.
  • Booked as day-only procedure
  • No HDU/ICU beds available. Other elective surgeries being cancelled.
  • Oxygen saturations 86% on room air after moving onto theatre table.
  • Extensive discussion with patient, surgeon, and anaesthetic colleagues about the risk of GA in day stay setting and no availability of HDU support.
  • Decision made to postpone and rebook with ICU bed as patient very unhappy with anything other than GA
  • At this point patient decides she will proceed with spinal.

Discussion

  • Opinion was that patient received a safe anaesthetic in the circumstances
  • Ethics difficult as patient left with little choices on the day
  • No local practice regarding day stay procedures in high BMI and OSA patients. See ANZCA professional document PS15 on Guidance for perioperative management of patients selected for day procedures.
  • consensus was that it would be an unsafe day stay procedure if opioids administered.
  • Many of these minor gynaecological procedures now being done under prilocaine spinal in the private with success (see attached BJA education paper on ambulatory spinal anaesthesia)