73yo male with a local recurrence of SCC around the cheek/infra-auricular area.

Background

• Facial SCC – WLE, neck dissection and radiotx March.
• DASI 6.6 METS
• PD – minor speech and swallowing changes
• Polycythaemia rubra vera – hydroxyurea and venesections q3/12
• Iron deficiency anaemia
• NHL – Chemotx, treated

Issues

• HOCM
  • Known since 2016, mod on TTE
  • Cardiologist review due to 6/12 history of worsening SOB
  • SOB and angina with slight inclines
  • TTE Aug ’21 showed severe LVOT obstruction, gradient 86mmHg
  • Cardiologist commenced beta-blocker
  • Ongoing review – Holter to look for ventricular tachydysrhythmias, ? will need defib, ? add disopyramide. 
  • Family to be referred for genetic testing

• Timing of procedure
  • Ongoing cardiac workup and modification
  • Surg team keen to avoid delays where possible, due to previous local metastasis

• Anaesthetic technique – surg reg suggests could be done under LA
• Airway
  • Moderately difficult BMV and grade 2 laryngoscopy in March
  • Patient notes reduced MO since radiotx

Discussion

• Anaesthetic technique
  • LA spread may be unreliable due to previous surgery
  • Concerns about sedation with likely difficult airway if conversion to GA required mid-case
  • Low physiologic stress procedure. Stress not appreciably reduced by loco-regional technique rather than GA.
  • HD stability desirable with HOCM

• Timing
  • Thought that if Holter reassuring and asymptomatic from recent beta-blocker addition, then appropriate to proceed without delays to cancer surgery.
  • Likely that the degree LVOT obstruction is unchanged since previous anaesthetic in March, which was well tolerated.

Plan

• Discuss Holter result with cardiologist – further treatment adjustment needed? disease severity likely stable since March.
• Notification of procedural anaesthetist – airway assessment and plan on DOS. Patient aware that AFOI may be required.