Cancellation on day of surgery: 19-year-old for wisdom tooth extraction

Background

• Ex-premature baby; 25 weeks
• Mild developmental delay
• Autism

Issues:

• Attended hospital on day of surgery with her father but declining to come to theatre and declining premedication
• Anaesthetist reviewed patient in day stay, stated has had previous traumatic experiences in theatre as a child where she felt she was having medical procedures against her wishes.
• Patient stated she doesn’t have any dental pain and doesn’t need or want to have teeth extracted
• Father had signed consent form but is not official enduring guardian
• Procedure was cancelled in accordance with the patient’s wishes 

Discussion

• Formal assessment of capacity is required in this case. 
• Consensus was that the patients reasoning was sound, and cancellation of the procedure was the correct course of action
• Social work contacted and will attempt to facilitate capacity assessment and ascertain if there is a requirement for an enduring guardian
• Social work will attempt to source NDIS funding for psychological support
• Grey area in adults – no psychological or social support for those with PTSD to mitigate stressors of attending hospital/OT as there are for children.
• Significantly, agreement that even if patient doesn’t have legal capacity, it is very difficult to carry out minor (non-life or limb-threatening procedures) if they are not willing.
• Patient advocacy processes should be clearly laid out in these cases

Plan:

• Await formal assessment of capacity
• Face to face review of patient preoperatively

Consult: 91-Year-old man for consideration of excision of ear SCC and possible temporal bone flap resection.

Background

• Early Alzheimer’s dementia
• No major cardiorespiratory co-morbidities
• Chronic pain – previous issues with opioid analgesia exacerbating cognitive decline, stable on current regime of Ibuprofen, Paracetamol and PRN Oxycodone

Issues

• Mild Alzheimer’s dementia – regular review by geriatrician over the last 4 years.
• MoCA score 20/30. Montreal Cognitive assessment Tool. See www.mocatest.org
• Lives independently with wife in a retirement village, happy with current QoL
• SCC right ear, increasing in size despite previous resection

Discussion

• Significant risk of both reversible and irreversible cognitive decline. 
• Patient and wife understand this risk and are keen to proceed.
• Non-surgical option would be radiotherapy however, patient lives rurally and would have to travel to Port Macquarie every day for treatment. 
• Both patient and his wife feel that radiotherapy would be create significant stress to their current lives. 
• Untreated SCC is an unpleasant disease with significant pain and lifestyle limitations

Plan

• Proceed to surgery as planned 

Consult: 77-year-old man for consideration of laparoscopic partial gastrectomy

Background

• Recent hospital admission with Haemoglobin of 48, inpatient blood transfusion and iron infusion 
• Imaging revealed distal gastric tumour, no metastatic disease.
• Severe COPD
• AF – NOAC
• Asbestosis
• Peripheral Vascular Disease – previous bilateral LL stents
• CKD – Stage 1

Issues

• Spirometry in clinic and subsequent formal PFTs showed FEV₁ = 0.91 (39%), PEFR = 23%, FEF_25-75%=16% predicted.
• Recent Exacerbation COPD requiring steroid therapy
• Troponin rise to 50 during last admission, associated with anaemia
• Echocardiogram unremarkable
• DASI 3.9 MET’s
• CFS = 5. Scores greater than 3 indicate increasing risk of adverse perioperative outcomes. See Rockwood article on clinical frailty DOI:10.1503/cmaj.050051

Discussion

• Respiratory function very concerning, has stopped smoking and has regular reviews with respiratory physician. On optimal therapy.
• Increased risk of postoperative pulmonary complications:
  • GUPTA Postoperative respiratory failure risk =13% and postoperative pneumonia risk= 19%. 
  • ARISCAT score: 45 = High Risk of post-operative pulmonary complications.
• Aggressive pathology – opportunities for optimisation are time-limited
• Consensus that an open procedure would not be advisable in this patient. Surgical team in agreement with this assessment but should revisit this discussion preoperatively

Plan

• Further discussion with surgical team regarding meeting outcomes
• Proceed with laparoscopic gastrectomy
• ICU 2 postoperative bed

86-year-old man for consideration of laparoscopic right hemicolectomy

Background

• Malignant Caecal Polyp = Not fully excised at colonoscopy
• No evidence of metastatic spread
• COPD – Last exacerbation 2018, required hospital admission
• Type II MI in context of LRTI
• AF – anticoagulated
• Moderate MR 
• Mild OSA

Issues

• Exertional dyspnoea at clinic, spirometry showed severe obstruction with good bronchodilator response.
• Chest pain, new symptom. Occurring weekly. No cardiology follow-up since 2018
• Clinical Frailty scale 5
• Advanced age
• Perioperative risk assessment – NSQIP scoring above average for all variables including a 47% risk of functional decline and approx. 20 % risk of serious complications, discharge into care, and delirium. SORT score gives a 7% risk of death for an elective procedure

Discussion

Surgical options

• Is there scope for repeat colonoscopy/further attempt at excision or a luminal-based procedure.
• Disease prognosis –uncertain regarding expected progression of cancer.
• If there is an increased likelihood of bowel obstruction, may expedite decision for surgery.

Increased Perioperative risk

• Risks discussed with patient and his son at the clinic. They both expressed that the perioperative risks were too great for them to proceed. Patient currently has a reasonable quality of life and would not be accepting of functional decline.
• Life expectancy calculated to be < 5 years. Discussion regarding online prediction tools for life expectancy and their use in complex perioperative decision-making.

Optimisation

• Prehabilitation and pulmonary rehab would be excellent opportunities to optimize respiratory function
• Non-invasive stress testing and an echocardiogram should be performed preoperatively.
•  If attending prehab, we should initiate concurrent cardiac investigations. 

Plan

• Formal PFT’s and respiratory review organized
• Discussion with surgical team – prognosis and surgical options
• Liaise with GP regarding prehabilitation via Kaden centre or pulmonary rehab
• Non-invasive cardiac stress testing and echocardiogram
• Re-review in clinic with results of above 

UPDATE – surgical discussion. Histology revealed likelihood of very slow tumour progression. Surgeon in agreement with patient that no further management required at this stage. GP to organise prehab/pulmonary rehab and cardiac testing.