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