73-year-old man for Right laparoscopic adrenalectomy

Background:

• Large adrenal adenoma – phaeochromocytoma excluded after extensive investigation
• Cushing’s
• Hypertension and high cholesterol
• DASI 6.2 METs

Issues:

• New ejection systolic murmur and RBBB noted in clinic
  • Echo – severe AS.
  • Exertional dyspnoea after 30 minutes of mowing. No angina
  • Surgery postponed for Cardiothoracic review
• AVR with tissue valve 6 months ago, no anticoagulants
• Recent admission:
  • HB 42 and melaena
  • FBC unremarkable otherwise.
  • Upper GI investigations normal.
  • Transfused to Hb 80. Currently stable.
  • Anaemia screen – negative
  • Colonoscopy – 2 years previously for positive family history. NAD. No repeated as inpatient.
• Gastroenterology review – working diagnosis of angiodysplasia from AS. For review and possible pill cam as outpatient. Recommended to proceed with surgery if Hb remains stable.

Discussion

• Reviewed over 1 year at perioperative clinic
• Pill Cam – medicare requirements state requires colonoscopy within 6 months. Will take time, surgery already postponed.
• Erythropoiesis-stimulating agents (ESA)
  • Cochrane review supports short term uses perioperatively in anaemic patients not responding to Fe alone, in whom all other causes of anaemia have been excluded, and perioperative blood loss is expected to be 500ml or more.
  • No increase in 30-day mortality or perioperative adverse events
  • Preoperative ESA and Fe-therapy prior to non-cardiac surgery reduces need for transfusion, and when ESA given in higher doses, improves Hb perioperatively.
  • No evidence for improvement in patient-centered outcomes such as LOS and mean number of RBC units transfused per person
  • Concerns regarding increase in thrombotic events, therefore not recommended in patients with uncontrolled hypertension, recent coronary or cerebral ischaemic events, and disseminated malignancy. More evidence required in this area.
  • https://na01.safelinks.protection.outlook.com/?url=https%3A%2F%2Fwww.cochranelibrary.com%2Fcdsr%2Fdoi%2F10.1002%2F14651858.CD012451.pub2%2Ffull&data=04%7C01%7C%7Cbf8ce3e52b3a4976a26f08d9eb4c9d7d%7C84df9e7fe9f640afb435aaaaaaaaaaaa%7C1%7C0%7C637799536936050453%7CUnknown%7CTWFpbGZsb3d8eyJWIjoiMC4wLjAwMDAiLCJQIjoiV2luMzIiLCJBTiI6Ik1haWwiLCJXVCI6Mn0%3D%7C3000&sdata=OOq5EhSFwSdHcr%2FMoDwAucuPJk0EVVmjcbwdpIfuIwM%3D&reserved=0
• ESA could cause confusion in measuring blood loss in this patient
• How to give ESA’s:
  • 600units/kg S/c weekly at least 3 weeks preoperatively
  • Need to replenish Fe-stores first, even if normal as adequate stores are required to produce erythroid progenitor cells
• Ongoing discussion in conjunction with haematology – define group of patients who will benefit perioperatively

Plan:

• Monitor Hb
• No need for pill cam preoperatively if no ongoing losses
• Postpone 6/52, surgical team in agreement