Frail patient for TKR

Gabrielle Morris

80-year-old female for TKR. Previously postponed due to lower limb infections. 

Dermatologist input – legs as good as can be.

Background

  • Widespread OA with severe kyphoscoliosis
  • Mild Asthma, distant ex-smoker, FEV1 70%, FVC 85%, ratio 74%
  • Hiatus hernia
  • Low ex tolerance <4 METS
  • CFS 6, always requires 4WW and significant assistance with ADLs
  • TTE – mild PHTN, EF=61%
  • Iron deficiency anaemia

Issues

  • Iron deficiency anaemia
  • Frailty, concerns about recovery.

Discussion

IDA

  • Additional investigations required?
    • Longstanding since 3yrs.
    • GP has been treating with iron but nil additional investigations
    • Likely due to inadequate intake, but GI malignancy should be excluded (unlikely but endoscopies usually part of the routine workup)
  • Stress myocardial imaging – low exercise tolerance but nil active cardiac conditions/symptoms and RCRI class 1, so not indicated as per the ACC/AHA guidance.
  • Should surgery proceed?
    • Extensive risk discussions with patient and family members. Appropriate to proceed as this is in line with the patient’s values and understanding.

Plan

  • Speak with GP regarding Fe deficiency – are they satisfied that this represents poor intake rather than a more sinister cause requiring investigation. If so, proceed with further Fe infusion and surgery.
    • Update – GP only took over care ~6/12 previously. Feels that further investigation is warranted. 
    • Postpone surgery while awaiting above.