79-year-old man for laparoscopic Right Hemicolectomy on a background of Caecal cancer

Background:

• COPD – Current Smoker
• Pulmonary Fibrosis – New diagnosis on staging CT
• Multiple previous abdominal surgeries including AAA repair and aorto-bifemoral bypass grafting
• Alcohol excess
• Impaired fasting glucose

Issues:

• Surgical concern regarding the potential difficulties or laparoscopic surgery and chance of having to open
• PFT’s – significantly reduced TLCO = 16% and FEV1/FVC = 0.53 in setting of COPD and new diagnosis of pulmonary fibrosis
• Asymptomatic, DASI = 5.8. Plays bowls

Discussion:

Epidural Anaesthesia

• High chance of conversion to open
• Multiple risk factors for postoperative pulmonary complications
• Consensus that there are many options for regional anaesthesia if converts to open surgery
• Preoperative discussion with surgeon to confirm best technique for analgesia

Disposition

• Ideally ICU 2 postoperatively given co-morbidities and likely long and difficult surgery/possible open procedure
• Would it be reasonable to proceed if no ICU bed available?
• Consensus was no, this patient should have post-operative HDU as a minimum standard of care

Plan:

• Proceed as planned
• Regional anaesthesia recommended, technique as per surgeon and procedural anaesthetist
• Postoperative ICU 2