PIG Meeting: 8th July 2021

59yo female for hysteroscopy, D and C, Mirena.

Background:

• BMI 58
• ‘occasional’ diet related reflux
• Pt cancelled due to large BMI, unoptimised reflux, likely (but untested) OSA and concern Re aspiration risk in context of previous regurgitation upon extubation during last hysteroscopy
• Spinal attempted in bay (by 2 proceduralists) but not possible
• Referred back to GP to manage reflux (patient on nil medications normally) and further assessment/optimisation of OSA.

Discussion points

• OSA assessment and optimisation
  • Difficult to access, long wait list in the public sector.
  • As a limited resource we must utilise rapid access appointments in a targeted way to gain the most benefit.
  • Epworth Sleepiness Score >5 and STOPBANG score > 3 should be used to screen for the highest risk patients.
  • Optimisation not required prior to minor surgery.
  • Local guideline for pre-op testing and optimisation under development. 

• Aspiration risk
  • Reasonable to attempt to alter the patient’s risk profile before another anaesthetic given previous regurgitation event.
  • Ranitidine stores are no longer available in the preop clinic.
  • PPIs are available over the counter although they are more expensive than when prescribed.
  • Referred to GP for management of reflux and weight loss. 
  • Could consider longer fasting/duration of clear fluids before anaesthetic.
  • Gastric US is validated with high BMIs (https://doi.org/10.1093/bja/aew400) although potentially more useful as a rule-in test (i.e., high residual gastric volume present) rather than a rule-out test, due to the potential for fluid to be sequestered in other parts of the stomach.
  • Na citrate for induction.
  • Individual anaesthetist’s choice. Mixed opinions in the group regarding cancelling/proceeding with the case.