61-year-old male for THR

Background

• BMI 56
• OSA – severe AHI 86, can’t tolerate CPAP
• Chronic back pain
• Hiatus hernia

Issues

• OSA 
  • HCO3 normal, unlikely to have obesity hypoventilation syndrome
  • SpO2 on RA 97%
  • Patient cannot tolerate mask
  • Limited scope for optimisation apart from weight loss

• BMI 56
  • Likelihood of preoperative weight-loss small.
  • Evidence for weight loss strategies points to gastro-reductive surgery, but extremely limited public availability (especially with absence of metabolic syndrome) and expensive in the private sector.
  • There is merit at face value for preoperative weight loss, but no clear evidence to suggest improved outcomes.
  • Unusual that patient was offered surgery at this BMI.  See table below, obesity and smoking only co-morbidities with RCT evidence to support increased perioperative risk.

• SOBOE
  • Reviewed by cardiologist. Sestamibi normal. TTE showed diastolic dysfunction (diuretics commenced)
  • SOB thought to be multifactorial – diastolic dysfunction, obesity, deconditioning. 
  • Nil further cardiac investigations thought necessary by cardiologist

Click to access mja212109.pdf

Plan

• Proceed with surgery
• Encourage compliance, where possible, with CPAP
• ICU level 3
• Neuraxial technique and minimal sedation recommended.