Cancellation for discussion – Aspiration risk and OSA unoptimised

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.

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