PIG Meeting: 8th July 2021

77yo male with rectosigmoid cancer causing PRB and significant anaemia requiring transfusion recently.

Background:

• Severe AS – Balloon valvuloplasty 30th June with reduction in valve gradient to 44mmHg and large improvement in symptoms (SOB and presyncope resolved).
• Minor non-obstructive CAD on angiogram 2020
• NIDDM
• Cognitive impairment. MMSE 19/30. Recent delirium in setting of severe anaemia.
• Cerebrovascular disease with old lacunar infarct
• Dyslipidaemia
• Severe hip OA. THR postponed due to other medical issues.

Issues

• Severe aortic stenosis
  • Discussed with Dr Hatton (patient’s cardiologist): Very reassured by improvement of symptomatology. Expected deterioration with time. May never be a candidate for TAVI due to cognitive status but may have repeat balloon valvuloplasty in the future.
  • Low exercise tolerance with DASI 2.9, however able to climb up/down 4 FOS and walk 100m on flat, slowly with walking stick, no pauses or symptoms.
• Cognitive decline
  • Delirium risk perioperatively
  • Noticeable decline over last year. Cardiologist said some decline may be attributable to his severe AS, there may be some improvement post- valvuloplasty.

Discussion

• Perioperative risk
  • Long discussion with patient and daughter about NSQIP-guided risks of death (3.6%), serious complications (16%), delirium (21%) and functional decline (44%).
  • Daughter insistent that any additional functional needs postop will be catered for with family assistance and care packages at home.
  • Pt has a quiet life at home, especially during COVID-era, but enjoys his life and feels strongly that he’d like surgery to give him the best chance of cure. Accepting of risks.
  • Palliative radiotherapy (necessary due to current PRB if surgery didn’t proceed) would not be without burden for the patient/family.
  • Advanced care planning discussed, and he would like all active measures deemed suitable by the medical team.  

• ? optimisation possible
  • May need further transfusion or iron preop
  • Severe hip OA and cognition make physical prehabilitation challenging
  • Aortic valve at its best now, cardiologist suggested ideal to proceed now.

Plan:

• Repeat FBC and Fe studies
• Proceed with surgery.
• ICU level 2 postop for haemodynamic monitoring/support given severe AS.

PIG Meeting Notes

PIG Notes 1st July 2021

Cases

• ‘Not seen’ warning note
• Acute psychosis and hernia repair
• Blood product consent
• Dental extractions in preparation for cardiac surgery
• Hysteroscopy and IUD insertion in Patient with BMI 77
• ?Fat embolism post-THR

PIG Meeting: 1st July 2021

66-year-old lady admitted to ICU with decreased GCS post elective THR

Background

• CREST syndrome – Raynaud’s and oesophagitis.
• No DMARD/steroid therapy
• COPD – mild. Distant ex-smoker

Issues

• Revision/re-do THR in Private hospital with standard spinal anaesthetic
• Uneventful intraoperative progress
• Episode of postoperative chest pain. Fentanyl PCA commenced, had 20mcg in total
• 1 hour later, appeared ‘narcotised;’ confusion, pinpoint pupils, and decreased RR
• Fentanyl ceased
• 6 hours post-op, found with GCS 6, no response to naloxone or flumazenil
• BSL, CT brain and CT-Angio normal
• Commenced on Keppra and transferred to JHH ICU
• Intubated on arrival to ICU due to low GCS
• MRI revealed ‘Multiple focal areas of acute infarction and multiple micro-haemorrhages’ involving brainstem and bilateral Thalami.
• Working Diagnosis of fat embolism syndrome
• Troponin rise to 820, no ECG changes. Commenced on aspirin.

Discussion

• Interesting and very unfortunate case
• Unusual presentation, no hypoxaemia reported but did complain of chest pain
• No PFO on post-op echocardiogram
• Diagnosis of fat embolism is usually based on clinical findings, but biochemical changes may be of value. The major and minor diagnostic criteria by Gurd are outlined below.
• The major criteria are based on the classic triad of respiratory insufficiency, neurological impairment, and a petechial rash.
• For the diagnosis of fat embolism syndrome, at least one major and four minor criteria must be present.

PIG Meeting: 1st July 2021

56-year-old lady with endometrial hyperplasia for hysteroscopy, D&C, Mirena

Background

• 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.
• Hyperthyroidism

Issues

• Super-morbid obesity
• Dyspnoea on minimal exertion
• No previous cardiac investigations despite AF and multiple risk factors

Discussion

Perioperative optimisation

• 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

Anaesthetic Management

• 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
  
  

Plan

• 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

PIG Meeting: 1st July 2021

67-year-old man for 2 dental extractions in preparation for AVR

Background:

• Asthma – daily Ventolin for dyspnoea but no admissions or steroids
• OSA – compliant with CPAP
• TIA – 2019
• Chronic kidney disease – stage 3
• Chronic cellulitis and lymphoedema – on long term antibiotics

Issues:

• Severe AR – awaiting AVR.
• HFrEF – 39%
• AF – Apixaban and Sotalol
• Pulmonary hypertension – recent right heart catheter; PAP = 57mmHg
• NYHA class 3 Dyspnoea

Discussion:

Anaesthetic techniques

• High risk patient for low-risk procedure
• Dental extractions under local anaesthesia would be lowest risk
• General anaesthesia would carry significant risk of cardiovascular morbidity and require arterial line/prolonged recovery stay

Anticoagulation

• Maxillo-facial surgeons happy to perform 1-2 dental extractions on anticoagulation

Plan:

• Local anaesthetic approach with continuation of anticoagulation
• Discuss with procedural anaesthetist and surgeon

PIG Meeting: 1st July 2021

49-year-old lady for Laparotomy and Hysterectomy for fibroid uterus and menorrhagia      

Background:

• Very large multi-fibroid uterus
• Menorrhagia – Fe deficiency anaemia in past requiring Iron infusion
• Fit and healthy lady
• Active, normal BMI

Issues

• Jehovah’s witness, Provided advanced care directive regarding acceptable blood products
• Inconsistency between products listed on ACD and those available for use in Australia, for example, haemoglobin

Discussion

Consent for Blood Products

• Frequently find ACD from Jehovah’s witness patients that list products not available in Australia
• Helpful strategy is to direct patients to the Red Cross website, explain available blood products and ask them to discuss with relevant advisors as to which they are happy to accept
• Essential that patients are adequately informed and consented preoperatively
• Jehovah’s witness website has many resources, may be helpful for anaesthetists to review information that patients are provided by church
• Majority of people agreed that they document patient’s wishes with regards to blood products in the event of a life-threatening emergency.
• This is best done at the perioperative consult as patient may need time to consult with family and church

Clinical Strategies to avoid Blood transfusion in this case

Preoperatively:

• Optimising Haematinics, anaemia screen and replacement as appropriate
• Consider use of tranexamic acid or Mirena in menorrhagia
• Fibroids – embolization, Zoladex – reduces size, takes 6 months to work and undesirable side effects.
• Nutrition advice and weight loss if appropriate

Intraoperatively:

• Liaise with surgical team regarding expected blood loss/difficult of surgery
• Consider use of cell salvage
• Intraoperative tranexamic acid to be considered

Plan:

• All above strategies employed
• Liaise with surgeon and procedural anaesthetist
• Consider update of clinic guideline/proforma – ongoing

PIG Meeting: 1st July 2021

37-year-old lady for elective repair of an epigastric hernia

Background

• Significant mental health history with multiple inpatient admissions – voluntary and involuntary
• Polysubstance abuse
• Multiple previous hernia repairs

Issues

• On day of surgery, patient thought she was being admitted for a caesarean section
• Support person confirmed this, and alleged patient had been using amphetamines recently
• Procedural anaesthetist reviewed patient who reiterated she was pregnant, and it was her due date.
• Patient thought that the investigations for the hernia were for obstetric purposes
• Beta-HCG negative
• Postponed in conjunction with surgical team
• Psych liaison contacted and recommended admission, but patient absconded post review
• Outpatient welfare visit and psychiatry follow-up organised by Psych-Liaison nurse

Discussion

Could the acute Psychiatric deterioration have been identified preoperatively?

• Unlikely, may have been very acute. Alleged recent excessive amphetamine use.
• Difficult via phone consult

Management of Patient

• Appropriate care provided to patient
• Unable to consent at time of elective procedure
• Psych Liaison services available at JHH and very helpful with this case

PIG Meeting: 1st July 2021

60-year-old lady for elective lumbar foraminotomy

Background

• NIDDM – HbA1C = 7%
• OSA – on CPAP
• Hypertension
• Current smoker
• Radiculopathy – bilateral foraminotomies at a lower level 6 months ago without issue

Issues

• Timing of booking/covid backlog/increased workload at periop clinic – no time to perform a perioperative consult
• Not seen warning note generated
• Cancelled on DOS as on SGLT2 inhibitor, not discontinued

Discussion

Could this cancellation have been avoided?

• Multiple factors contributing to failure to cease SGLT-2 inhibitor.
  • Patient had same surgery recently and it was ceased at that time
  • Discharge medications and recent perioperative instructions highlighted she was taking this medication
  • SLGT-2 not flagged on the RFA
• Patient may not remember medication instructions
• Surgical registrars often fill the RFA and may not be aware of the perioperative requirements for SGLT-2 inhibitors.
• Additionally, perioperative nurses are triaging many cases per day, they rely on the GP referral/RFA and often don’t have enough time to read through the previous clinic notes

Would it have been appropriate to proceed?

• Ultimately it is the decision of the procedural anaesthetist
• According to most recent ANCZA/ADS statement, it may be appropriate to perform day surgery on patients who have continued SGLT-2 inhibitors under certain conditions. (See table below)
• This surgery may be complex due to previous surgeries
• Patient has good glycaemic control but significant co-morbidities.
• Elective procedure, consensus that best to postpone

PIG Meeting Notes

PIG Notes 24th June 2021

Cases

• Elderly male, consultation for consideration of EVAR
• HBV in pregnancy, for elective Caesarean Section
• Endoscopies and pleural effusion
• TKR with incomplete revascularization

PIG Meeting: 24th June 2021

69yo male patient in private hospital for TKR

Background:

• IHD
  • NSTEMI March ’20, PCI, converted to single antiplatelet therapy after 12/12
  • Admitted recently with unstable angina, possible lateral t wave changes but no trop rise. No angiographic findings suggesting revascularisation required. Some very distal LCA territory disease.
  • Recommenced on DAPT.
  • Ongoing daily GTN for angina at rest.
• TTE shows mild apical hypokinesis and mildly reduced EF.
• ? Anti-Phospholipid syndrome
  • Patient diagnosed at one stage as positive
  • Further review by different haematologist and repeat results suggest patient does not have APL syndrome

Discussion

• Should surgery proceed?
  • GP encouraging patient to delay surgery, await further cardiologist review in 3/12
  • Cardiologist says patient may proceed with surgery now, happy for w/h of clopidogrel
  • Perioperative revascularisation reserved for lesions with a significant vascular territory (left main disease) or symptomatology. ? revasc not being offered despite daily symptoms, as not amenable to stenting.
  • Differential diagnosis:
    • Non-cardiac cause of chest pain due to essentially normal TTE in the setting of daily rest pain (e.g., recurrent PEs due to APL syndrome)
    • Non-anatomical cause for coronary ischaemic pain e.g., coronary artery thromboses from APL syndrome

• ISCHEMIA trial showed that even with moderate to severe obstructive lesions, routine invasive therapy was not associated with a reduction in major adverse cardiac events compared to optimal medical therapy. (See attached article)
  • Patient leaning towards delaying surgery (which seems sensible from a purely elective surgery perspective) however, unlikely that anything will change before cardiology review to further guide the decision.
  • If surgery does proceed, patient may be a good candidate for postoperative troponin testing.
• APL syndrome
  • Confusing picture with alternate haematologist views
  • Is perioperative Tranexamic acid safe? Brief literature search suggests, and group consensus was, that TXA use is not associated with increased risk of VTE in this setting.
  • ? impact on stent thrombosis risk

Plan:

• Patient currently postponing surgery
• When/if surgery planned in future, formal discussion with current haematologist  to ensure that the APL issue has been fully elucidated
• Further discussion with treating cardiologist to guide postoperative monitoring/investigations given his IHD.