Lap chole and clozapine

garychleung

PIG Meeting: 1st April 2021

67yo female for lap chole due to recurrent obstructive jaundice and cholangitis, with one episode causing severe septic shock requiring ICU for vasopressors. Surgery cancelled twice already due to resp status.

Background:

  • Schizophrenia
  • Dyslipidaemia
  • COPD
    • Active, heavy smoker
    • 2 exacerbations this year
    • SpO2 88-93% on RA
    • During exacerbation, FEV1 0.63 33% predicted (previously 1.1L, 50%)
    • Feels she has now returned to her baseline
  • Impaired glucose tolerance
  • BMI 37
  • Neurocognitive disorder – on donepezil
  • Hypothyroid – treated
  • Lives in group home, guardianship order

Issues

  • Should surgery proceed?
    • Surgeons have suggested that if she is predicted to survive 1yr+ (from her other comorbidities) then surgery should proceed
    • High risk of further severe illness related to gallstones
  • Can she be optimised?
    • Resp physicians have suggested that nil further optimisation possible while she continues to smoke
    • On appropriate medical therapy

Plan

  • Reasonable to proceed with surgery given risk of critical illness without it.
  • Tar in cigarettes induces enzymes in the liver, resulting in more rapid clozapine metabolism. Risk of clozapine toxicity with smoking reduction/cessation therefore exercise caution.
  • Liaise with clozapine coordinator to ensure all appropriate investigations up to date and to enable clozapine prescription while in hospital (see attached HNE guideline)
  • Nil anticipated missed doses of clozapine with this surgery
  • Prewarning of the procedural anaesthetist