Semi urgent minor surgery, recent PCI

Gabrielle Morris

83yo male for cystoscopy and stent exchange due to chronic obstruction from uroepithelial carcinoma.

Background:

  • Uroepithelial carcinoma
  • PVD
  • Impaired glucose tolerance
  • AF. On apixaban.
  • PPM for CHB (99% paced, underlying AF).
  • HTN
  • Dyslipidaemia

Issues:

  • Recent PCI 
    • Type 2 MI Post-operatively after stent insertion
    • Ongoing intermittent chest pain last 6/12
    • PCI + rotablation for severe ostial RCA stenosis. 3/52 ago
    • For lifelong clopidogrel and apixaban.
    • Ureteric stent now 7/12 old, urologists keen ++ to replace

Discussion

Ideal timing of surgery?

  • Discussed with treating cardiologist: happy to proceed 4-6 weeks post-PCI
  • Requests to continue clopidogrel perioperatively. 
  • Discussed with surgeon – happy with plan

Communication in the perioperative clinic

  • Much time spent attempting to phone proceduralists and clinicians, they are often busy/scrubbed and then call back when we are with another patient 
  • Email often a more effective tool – ability to CC all relevant clinicians and the HNELHD-JHHPeriopnurse@health.nsw.gov.au perioperative nurse address. 
  • Provides a paper-trail of communication. Encourages multidisciplinary engagement. 
  • Clinician email addresses usually available on their letterhead/website. 
  • The urology registrars are setting up an email address to allow us to create a bank of patients for them to ask their consultants about on a regular basis. 

Cardiac Investigations in this patient post initial Type 2 MI

  • Interestingly this patient had a sestamibi which showed ‘no major area of inducible ischaemia’ and that patient had no chest pain throughout the protocol. 
  • Note that the stress ECG component of the test is difficult to interpret in the present of Ventricular-pacing. 
  • See article on non-invasive cardiac stress testing (http://dx.doi.org/10.1136/heartjnl-2015-307764).)