66yo male declined from a small peripheral hospital for cataract surgery. 

Background

• Cataract surgery on one side previously. Poorly tolerated with possible contributors from APO/claustrophobia/anxiety.
• OSA – not on CPAP
• AF, no embolic events, on apixaban
• T2DM, HbA1c 9.1%
• CKD stage V, fluid restriction 1.7L. Recent review by Renal Outreach Team (palliative care physician led). Decision reached that this patient was not suitable for dialysis. Comfort and QoL goals of care, rather than life-prolongation.
• Recent APO – due to non-adherence with fluid restriction. TTE showed atrial flutter, mildly reduced RV systolic function, normal LV.
• PEA arrest due to type 2 respiratory failure. Managed with NIV.

Issues

• Should surgery proceed?
  • Cataracts can be considered a palliative, QoL enhancing operation.
  • Really necessary with one cataract already done? – apparently the gains are significant. Recommended by ophthalmologist.
  • HbA1c is only modifiable feature, but the surgeons are unconcerned and at this palliative stage of the patient’s life journey, unnecessary to push for an improvement.

• Anaesthetic technique?
  • Unlikely that the block/sedation will be well tolerated.
  • With fluid status well controlled with fluid restriction and a reassuring TTE, seems unlikely that there are CVS concerns that prevent a GA for this low-physiologic stress procedure.
  • With short-acting agents and no opioid requirement postop, a recurrence of his previous type 2 resp failure seems unlikely.

Plan

• Proceed with surgery under GA at JHH.