77-year-old man with gastric cancer. Previously discussed at PIG as a consult.
- COPD- severe obstructive disease. FEV1 – 0.95, FVC – 3.36
- AF – DOAC
- Presented with UGI bleed – Hb 48. No opportunity for NAC or optimisation
- Referred to respiratory physician for investigation of lung masses. Thought to be non-cancerous.
- Living at home with exertional dyspnoea
- Patient and family keen to proceed with curative surgery
- Admitted for procedure – lap assisted distal gastrectomy
- ICU post-operative for 24 hours
- Discharged to ward
72 hours post-op:
- Acute dyspnoea, APO, and AKI. Readmitted to ICU
- Treated for HAP; High-flow oxygen, fluid overloaded.
- Creatinine increasing, anuria, and delirium
- CT showed no surgical complications, echo – nil significant
- Difficult situation – no way forward.
- Evidence – When to start dialysis? Outcomes unchanged when started earlier vs later. Surgical patients do better but likely better baseline than medical patients.
- MDT meeting – dialysis commenced over 5 days. Stabilised and went to ward. Declined again and now palliative.
- Preoperatively predicted that this would be a likely outcome if had any postoperative complications involving major organs
- Family well-informed preoperatively