PIG Meeting: 1st July 2021
56-year-old lady with endometrial hyperplasia for hysteroscopy, D&C, Mirena
- Obesity Hypoventilation syndrome – on home BiPAP, compliant
- Asthma – recent admission with exacerbation of asthma and type 2 respiratory failure
- Spirometry; FEV1 = 0.8 (33%) and FVC = 1.4 (42%)
- AF – Apixaban and metoprolol. Rate-controlled.
- Super-morbid obesity
- Dyspnoea on minimal exertion
- No previous cardiac investigations despite AF and multiple risk factors
- Dyspnoea – likely multifactorial due to obesity, respiratory disease, and deconditioning.
- Regular review by respiratory physician ongoing
- Should we exclude cardiac causes? Not required preoperatively for this procedure, but prudent to begin process of investigations as will likely require repeated procedures and ultimately, a hysterectomy.
- Discussed at cardiology meeting – advised proceed as planned, should have BNP and if significantly raised then organise an Echocardiogram
- Opioid-sparing anaesthetic options discussed: sedation with THRIVE/BiPAP, spinal.
- Similar cases discussed that have been performed under ketamine sedation and using THRIVE
- Difficult to perform as a day case if opioids administered.
- ANZCA document PS15 ‘Guideline for the perioperative care of patients selected for day stay procedures.’ advises that patients with confirmed or suspected OSA should have minimal post-operative opioid requirement and ideally discharge analgesia should not include opioids.
BNP as a diagnostic tool
- Increases in Plasma BNP can indicate a diagnosis of HFpEF or HFrEF
- Also used as a biomarker in pulmonary hypertension
- Differentiate between pulmonary cause of dyspnoea and undiagnosed Heart Failure
- The Breathing not properly study (attached article) showed low plasma concentrations of BNP had a negative predictive value of 96%
- Suggested in this case as an Echocardiogram would be technically difficult and may not be required if BNP normal
- Affected by obesity – lower plasma concentrations seen in obese patients
- Discussed with procedural anaesthetist – aim to perform procedure with BiPAP and sedation
- BNP to be done on admission to hospital as patient has no way to travel to pathology, results to be discussed at cardiology meeting if required