PIG Meeting: 8th July 2021
59yo female for hysteroscopy, D and C, Mirena.
- 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.
- 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.