62-year-old lady for Laparoscopic Hiatus hernia repair /Fundoplication
Background
- Epilepsy
- Right hemicolectomy – Iatrogenic Perforation post colonoscopy
- Significant mental health conditions – Bipolar affective disorder, PTSD, anxiety
- Chronic back pain, known to HIPs. Using cannabis oil, no opioids.
- Fe-deficiency anaemia
Issues
- Symptomatic Hiatus Hernia/GORD/Oesophageal dysmotility
- Recurrent aspiration pneumonia
- 5-6 admissions in last 2 years
- Sleeps on bed wedge
- Eating clear soups and fasting from 5pm.
- Moderate COPD:
- Formal PFTs: FEV = 1.34 (55%) DLCO = 42%
- FEV1 in clinic significantly decreased from previous; 0.82 (39%)
- Clinically not dyspnoeic
- DASI 3.9 METs. Independent with ADL’s
- Pulmonary nodules – non-malignant, thought to be inflammatory
Discussion
Perioperative Optimisation
- Recent spirometry indicates pulmonary function has deteriorated
- sequelae of recurrent aspiration pneumonia?
- Clinically no change
- Clinic spirometry – often difficult to obtain good technique and therefore, accurate results
- Formal PFT’s would be useful in this circumstance though unlikely to change management
- Regular review by respiratory physician:
- Optimised, LABA and 2 inhaled steroids
- Concerned regarding recurrent aspirations and feels surgery should proceed
Risk of postoperative pulmonary complications (PPC)
- ARISCAT score = 13.3%, intermediate risk of in-hospital PPC
- GUPTA – 13.7% risk of post-op pneumonia
Disposition
- Open vs lap, unusual to have to convert to open procedure
- If open, would need rectus sheath catheters and possible ICU 2
- ICU 3 suitable for laparoscopic procedure planned
Plan
- Formal respiratory function tests and discussion with physician if any change
- ICU 3
- Discuss with procedural anaesthetist