Hernia repair, severe resp disease

61yo male with an umbilical hernia which is increasing in size and with recurrent incarcerations.

Background:

  • Severe bullous emphysema
    • Distant ex-smoker
    • Regular review by respiratory physician
    • Distant lung reduction surgery.
    • Endobronchial valves on right side inserted ~ 10yrs ago. Designed to reduce distal gas trapping.
    • Previous spontaneous Pneumothorax
    • Home O2 (concentrator)
    • 4 x admissions with exacerbations, last in ’20, nil ICU.
    • Formal PFTS: FEV1 1.15 (36%), FVC 3.82 (94%), bronchodilator responsive, TLCO 48%
    • Desaturated to 74% with ~50m walk. Declined stairs.
  • Clinical Frailty Scale 4 
  • T2DM – OHA, HbA1c 7.2%
  • Dyslipidaemia
  • Chronic back pain, opioid tolerant

Issues and discussion

  • Should surgery proceed
    • Without elective procedure, the patient will likely present for an emergency procedure, perhaps critically unwell, due to an incarceration or strangulation.
  • Severe respiratory disease
    • BODE index 80% mortality at 52mths.
    • GUPTA postop resp failure 5.45% risk
    • Short course of high dose steroids indicated preoperatively? With such critical lung disease any gains welcome. See attached article.
  • Anaesthetic technique?
    • What is the implication of the endobronchial valves if GA with PPV indicated?
    • Procedure under combination of regional anaesthesia (rectus sheath blocks) and top up with LA by surgeon ideal.
    • Risk of precipitating respiratory failure (or at least respiratory anxiety!) if intercostal muscles inactivated by high SAB.
    • Slowly titrated EDB an option.
    • Regional/neuraxial ideal for post-op analgesia.
    • GA an option – Lung volumes and TLCO reassuring, however risk of bullae rupture.

Plan and Requested Actions:

  • Respiratory physician discussion. Update:
    • Physician felt that this patient has been stable for several years
    • Recent review suggested no targets for optimisation
    • Preoperative prednisone won’t cause harm but unlikely improvement due to the bullous nature of this patient’s emphysema.
  • Intraoperative implications of the endobronchial valves. Update:
    • Spoke to Cardiothoracic team – no local experience.
    • Spoke to resp team (who insert and manage these valves) – no implications for PPV.
  • If GA required; low pressures, spontaneous ventilation where possible, and cognisant of risk of bullae rupture. 
  • ICU level 3