PIG Notes July 22nd 2021

• Colonoscopy after recent PE
• Major vascular surgery and angina
• CEA and triple vessel disease
• TKR and OSA
• EVAR with severe COPD

83-year-old lady admitted to hospital with abdominal pain. Incidental finding of 6.4cm infra-renal AAA

Background

• Severe COPD, recently commenced on home oxygen
• Recent admission with infective exacerbation 
• Type 1 respiratory failure, Room Air PaO₂ = 55mmHg
• Spirometry – FEV₁/FVC: 0.99/1.48: 0.67. TLCO 37%
• HFpEF. 1.5 litre fluid restriction
• Pulmonary hypertension, moderate
• Large hiatus hernia with uncontrolled GORD
• Severe kyphosis

Issues

• Incidental finding of AAA, suspicion of leak on scan
• Ongoing abdominal pain
• Haemodynamics and Haemoglobin stable

Discussion points

Should surgery proceed?

• Large aneurysm, annual rupture rate around 10%
• Respiratory physician opinion that survival from COPD is “a few years.”
• Patient keen for procedure, has supportive family and great-grandchildren nearby
• Not suitable for an open procedure
• Patient and family fully aware of risks
  
  

Optimisation

• Echocardiogram? Enable assessment of LV function and Pulmonary hypertension – not likely to change management

Conduct of Anaesthesia

• Sedation vs GA vs epidural
• Patient can lie flat without significant dyspnoea, but procedure expected to last around 90 minutes
• Breath-holds required and can be painful
• Aspiration a concern with sedation
• GA may facilitate faster procedure
• Aim to extubate at end of case
• Epidural may prove difficult given kyphosis

Disposition ICU bed if GA/any complications

76-year-old lady for elective TKR

Background

• Significant knee pain, impacting QoL
• COPD, mild. 60 pack year smoking history
• Ceased smoking to facilitate TKR
• Peripheral vascular disease, multiple revascularization procedures. On apixaban
• BMI 46
• NIDDM. Poor glycaemic control
• Difficult to obtain accurate history in clinic
• Some indications of poor medication compliance
• On ?CPAP for OSA. Advised to bring to hospital.
• Extensive perioperative work-up, including delay to improve glycaemic control

Issues

• Presented for TKR. Uneventful intraoperative course.
• Developed Type 2 respiratory failure in PARU
• Home machine not functioning due to water ingress, sent to biomed
• Commenced on NFNP with little effect
• Reviewed by respiratory CNC in PARU. Patient well known to service
• Patient has significant OHS and is on home BiPAP (IPAP 17, EPAP 9)
• Device history revealed recent non-compliance with therapy
• Respiratory department sourced a replacement machine.
• Patient stable in recovery on usual BiPAP settings and discharged to ward.

Discussion

Conduct of anaesthesia

• Spinal with intrathecal morphine 100mcg – consensus opinion that this was the optimal anaesthetic choice as avoided parenteral opioids.
• Some anaesthetists routinely use 150mcg morphine but would decrease to 100mcg in patients at risk of postoperative respiratory depression
• Consensus in literature than 100mcg is optimal dose for avoidance of respiratory depression

Could this situation have been avoided?

• Difficult history, multiple complex comorbidities
• Patient unaware of differences between CPAP and BiPAP
• Non-compliant with therapy
• Respiratory CNC provided extremely valuable input and avoided an unplanned HDU admission

Perioperative management of suspected OSA/OHS

• Clinic guideline under development, ongoing discussions with respiratory dept
• Sleep studies are time-consuming and turnaround time from referral to initiation of CPAP is around 6 months
• No RCT evidence to support reduction in perioperative morbidity and mortality with initiation of CPAP therapy.
• Observational data would suggest that OSA patients have worse perioperative outcomes and there are benefits to initiating CPAP perioperatively. (Anesth Analg 2015;120:1013–23)
• Aim is to identify those at highest risk of postoperative pulmonary and cardiac complications
• OHS – more complex sleep disorder with raised HCO₃ and PaCO_2. Majority also have OSA. These are patients to identify and treat perioperatively.
• Perioperative assessment: STOPBANG (>3) then perform ESS. If ESS (>8) – consider referral for sleep studies

55-year-old lady for Right Carotid Endarterectomy

Background

• Bilateral carotid artery stenosis: Right 99%, Left 90%
• Symptomatic – multiple TIAs with left hemiparesis.
• Right temporoparietal watershed infarct on MRI
• Vertebral artery disease – possible small dissection on imaging
• NIDDM. HbA1c = 6.7%
• IHD with multiple previous PCI’s
• Ischaemic cardiomyopathy, LVEF 45%

Issues:

• Recent NSTEMI (in WA)
• Significant triple vessel disease on angiogram
• Treating team felt CVA risk too high for CABG, opted for PCI
• PCI in June 2021: 1x DES to prox RCA, 1x DES to Mid-Cx, 3x overlapping DES to LAD
• Now on Ticagrelor
• Recent echo showed hypokinesis of inferior and septal walls

Discussion

• Complex and high-risk cardiac and cerebrovascular disease!

Management of anti-platelet therapy

• Ticagrelor – oral, reversible, direct-acting P2Y12 inhibitor. Ticagrelor has a more rapid onset and more pronounced platelet inhibition than clopidogrel. See attached PLATO trial.
• Vascular surgeon happy to perform CEA on Aspirin/Clopidogrel but not on Ticagrelor due to increased bleeding risk.
• Current plan to cease Ticagrelor 3 days preoperatively
• Unclear if patient was on DAPT when had recent NSTEMI
• If had NSTEMI on Clopidogrel, should we consider performing platelet function studies?
• Discussed at Cardiology meeting – DAPT would be ideal solution

Timing of Procedure

• Booked for September, 3 months post-PCI
• Consensus is that it would be acceptable to proceed earlier given significant disease and ongoing risk of CVA

Procedural Issues

• Shunt – bilateral disease along with possible vertebral artery dissection, would the proceduralist opt to shunt prophylactically?
• Majority felt that shunt would be most likely performed in this case but should be discussed further with proceduralist

Disposition

• Postoperative ICU for strict BP control and haemodynamic monitoring
• Should we consider postoperative troponins?

Plan:

• Further discussion required with proceduralist and cardiologist regarding timing of surgery and management of antiplatelet medications
• Postoperative ICU bed

49-year-old lady for complete endovascular reconstruction of Aortic bifurcation, endoluminal graft, and reconstruction of aorto-iliac segment.

Background

• Significant peripheral vascular disease – intermittent claudication, limiting all exercise.
• Wheelchair bound outside home
• Morbid obesity
• NIDDM. HbA1c = 5.8%

Issues

• Recurrent episodes of angina on minimal exertion over the last 3 months
• Exercise stress echocardiogram performed – submaximal test due to leg pain. Exercised 3-4 METs and reached 69% of predicted heart rate
• Chest pain during test, normal ECG and no exercise-induced Regional Wall Motion Abnormalities or reduction in end-systolic volumes
• CTCA recommended by treating cardiologist
• CTCA – Left main disease. ‘Extensive CAD with at least 50-69% stenosis in left main and mid RCA.’ Calcium score 439 (above 95^th percentile)
• Discussed at cardiology meeting. Plan to postpone and perform coronary angiogram

Discussion

CTCA

• Discussion as to the value of the test in this patient
• Young patient but high calcium score not unexpected given existing vascular disease
• Coronary CTA VISION study – evaluated role of CTCA in perioperative risk stratification.
• Results showed patients were x 5 times more likely to have an inappropriate over-estimation of surgical risk based on RCRI after coronary CTA
• Coronary angiogram likely to be a better test in this patient

LM disease

• CABG vs PCI discussed
• Traditionally, left main disease was an indication for CABG
• Extensive area of myocardium involved with increased potential for morbidity and mortality
• Evolution of practice, newer generation of DES, and improved adjuvant drug therapy has created better outcomes for PCI in LMCA
• 2 recent RCT’s EXCEL and NOBLE compared revascularization with PCI to surgical techniques with conflicting results.
• Both trials showed similar long‐term survival rates to CABG surgery, particularly in those with low and intermediate anatomic risk. 
• However, patients undergoing PCI had higher need for repeat revascularization in the future.
• Which patients are suitable for PCI? Current guidelines from AHA state they ‘strongly recommend surgical revascularization for LMCAD (class IA) with PCI considered a reasonable alternative (class II) in select patients with less complex anatomy and clinical characteristics that predict an increased risk of adverse surgical outcomes.’
• https://www.ahajournals.org/doi/10.1161/JAHA.117.008151

Plan

• Discussed at cardiology meeting – to proceed to coronary angiogram
• Patient and surgeon aware of plan.

72-year-old man for gastroscopy and colonoscopy

Background

• Surveillance colonoscopy for previous benign polyps
• Gastroscopy for chronic GORD symptoms
• BMI 57
• NIDDM, good control
• PAF, on Apixaban
• Pulmonary Hypertension, routine echo in 2017

Issues

• Recent Bilateral PE’s (April 2021) with significant clot burden
• Admission with sepsis and AKI 2 months previously and DOAC ceased
• No investigations for OSA; STOPBANG 8 and Epworth Sleepiness Score 12
• Not known to respiratory physician and no follow-up in place from hospital admission

Discussion

Should procedure be postponed?

• Yes. Elective procedure. No red flags.
• Surgical team in agreement.
• Postpone until 6 months post PE.
• Postponement of 3 months is usually adequate. A longer timeframe was selected in this patient due to the severity of his disease and complex comorbidities.

Optimisation

• Referral to respiratory physician; significant clot burden, should he have repeat imaging before interruption of anticoagulation?
• Clinical suspicion of OSA (and possibly OHS) given multiple risk factors, ESS, and long-standing pulmonary hypertension.
• Plan to discuss with respiratory physician

Plan

• Postpone for at least 3 months
• Repeat echocardiogram
• Referral to respiratory team

PIG Notes 15th July 2021

• Bronchial Thermoplasty
• Carotid endarterectomy v. stent
• Bilateral TKR
• Frail patient for e/o SCC and craniectomy
• ? Cardiac amyloid
• HOCM and PAF for hernia repair
• Trifascicular block and urological stent

85-year-old man for cystoscopy and stent change

Background

• Metastatic prostate cancer
• IDDM – HbA1c = 11.7%
• Increased BMI
• OSA
• Asthma

Issues

• Recent admission with AKI and obstructive uropathy, thought to be caused by pelvic metastatic disease
• AKI ongoing despite stent
• Trifasicular block on ECG – 46bpm
• Asymptomatic, present on ECGs from admission last year
• History of unexplained falls attributed to postural hypotension and resolved with cessation of antihypertensives

Discussion

Management of trifasicular block perioperatively

• Discussed at cardiology meeting – Not for pacemaker therapy at present; asymptomatic, multiple co-morbidities, increased risk of infection, but does present uncertain risk of developing complete heart block intraoperatively
• Consensus that there should be a clear management pathway for patients at risk of perioperative bradyarrhythmia that are unsuitable for PPM therapy
• Increasing numbers of similar presentations

Risk of perioperative complete heart block

• Difficult to define
• Literature is contradictory at best
• Recent case of perioperative bradycardia with difficulty in obtaining temporary pacing. Not first line therapy but some concern that this issue be resolved before we decide to proceed with cases at known risk of perioperative CHB?

Plan

• Proceed with surgery in conjunction with procedural anaesthetist
• Optimise glycaemic control without postponing procedure
• Discuss at departmental M&M with reference to recent case

66-year-old man for open left inguinal hernia repair       

Background:

• Reducible inguinoscrotal hernia. Causing intermittent pain but no hospital admissions.
• Hyperthyroidism
• Epilepsy
• Anxiety/depression

Issues:

• HOCM – stable disease on medical therapy
• AICD in situ
• PAF – Associated increased dyspnoea, haemodynamically stable, severely dilated LA on echo, booked for AF ablation in coming months
• Commenced on amiodarone but recent device check showed an AF burden of 100%
• DC Cardioversion recently

Discussion:

Timing of surgery

• High risk of AF intraoperatively
• Recent cardioversion and need to cease DOAC perioperatively
• Should we wait until ablation is performed?
• Discussed at cardiology meeting and cardiologist feels it would be suitable to proceed but there is a risk of perioperative AF. Ablation success is uncertain in the settling of HOCM, and patient will be more likely to redevelop AF in the 3 months post-ablation
• On optimal medical therapy
• Elective surgery – consensus that it would be better to have ablative therapy preoperatively

Plan:

• Expedite ablation if possible
• Postpone hernia surgery until 3 months post-ablation

56-year-old man for a Radical prostatectomy for prostate cancer

Background:

• Asthma – well-controlled
• Lifelong smoker – 30 pack years
• Active, goes to the gym daily >4METS

Issues:

• Inferior TWI noted on perioperative ECG
• No history of symptoms
• Echocardiogram showed ‘moderately hypertrophic LV with marginally reduced systolic function, Grade 1 diastolic dysfunction, infiltrative process cannot be excluded, and ASD with small left>right shunt.’

Discussion:

• Discussed at cardiology meeting regarding need for further investigations preoperatively. Cardiologist recommended that surgery proceeds, cancer surgery.
• Differential diagnosis:
• Ischaemic Heart disease – relatively normal LV systolic function is reassuring.
• Infiltrative process – E.G. Amyloidosis, unlikely but at present it is not significant. Not obvious on echo and voltages preserved on ECG. Recommends post-op outpatient cardiology review and cardiac MRI
• AHA guidelines would support proceeding without further cardiac investigations
• Normal sestamibi would be reassuring but abnormal result would likely cause delay and not change intraoperative management

Plan:

• Proceed with planned procedure
• Refer to GP for postoperative cardiology referral and consideration of cardiac MRI and stress test.