Cancellation due to respiratory issues

Gabrielle Morris

70-year-old for laparoscopic Bilateral Salpingo-Oophorectomy and ovarian cystectomy

Background

  • CKD – stage 3
  • Complex ovarian mass
  • BMI 41

Issues

  • Severe COPD
    • Ex-smoker 60 pack years
    • FEV1=0.6 (31%), FVC=1.45 (52%)
    • Has preventer but doesn’t use, Ventolin a few times per week
    • Oxygen saturations 95% at clinic
    • No formal diagnosis/respiratory physician review
  • Decreased functional capacity, 4 MET’s
  • Pulmonary hypertension
    • Previous admission for fluid overload/HFpEF in 2016
    • No PND/peripheral oedema
  • In anaesthetic bay – described exertional angina and orthopnoea
    • uncertain history of NSTEMI.
    • Cardiologist review previously but hasn’t been seen for a while.
  • Discussed with surgeon on day, cancer unlikely. Agreement to postpone for investigation and risk-stratification

Discussion

  • Short notice patients in clinic due to covid cancellations and recovery
    • Imperative to discuss with proceduralist if any concerns
    • Patient was on gynae-oncology list, but not a cancer patient
    • Distance patient
  • Review process for Respiratory Rapid Access Clinic currently underway by Dr Papeix. Recent meeting with respiratory physician revealed:
    • Role for some patients to have a RAC review perioperatively
    • Minimal optimization achievable in setting of stable COPD. Approximately 20% would have eosinophilic picture and would benefit from inhaled steroids
  • Majority already on LAMA/LABA
  • Inhaled steroids overused in community and main function is to decrease frequency of exacerbations
  • Minimal role for inhaled steroids in reduction of perioperative risk
  • Asthma – Asthma control questionnaire. Role for management of asthma perioperatively. Oral steroids take weeks to improve control and for those that qualify for leukotriene-receptor antagonists, months
  • Cystic Fibrosis – regular review by specialist but should be seen preoperatively
  • Interstitial lung disease – some therapies which can impact systemic inflammatory process. Can take weeks to see improvements
  • Role for respiratory review in undifferentiated dyspnoea where cardiac cause has been excluded
  • Discussed at cardiology meeting – referral to cardiologist in local area for review and likely stress cardiac imaging

Plan

  • Postpone for 3 months
  • Await cardiologist and respiratory review
  • Follow-up in perioperative clinic