45yo female for whole body MRI. Previously attempted with oral anxiolysis due to severe claustrophobia but patient became extremely distressed. Repeat attempt booked today under GA.

Background:

• ? Myositis
  • Subjective muscle weakness since 18mths
  • CK 1500, weakly positive myositis antibodies
  • Rheumatologist advises only avenue for diagnosis is whole body MRI
  • Chest pains – CTPA negative, costochondritis, referred to cardiologist, CT heart (? CTCA) pending.
• HTN
• Asthma
• BMI 55
• Ex-tolerance 50m
• PCOS (metformin)
• Likely severe OSA (declined testing due to claustrophobia)

Discussion

• Should procedure occur today?
  • Not reviewed in periop clinic as these bookings do not come through the surgical services pathway
  • Non-urgent procedure given lack of progression of symptoms over 18mth time frame.
  • Rheumatologist and patient both pushing for MRI today.
  • Remote location

• What would we optimise if review had occurred?
  • OSA won’t affect this procedure (no incision, no opioids afterwards), patient declining testing and CPAP.
  • Significant preoperative weight loss unlikely
  • Ideal to know the outcome/concerns of the cardiologist involved, documentation missing.

Plan:

• Attempt to contact cardiologist by phone. If they do not feel that severe IHD or other cardiac issue is likely, then should proceed with MRI under GA.

If cardiologist not able to be contacted and anaesthetist feels the low exercise tolerance and chest pain have a high pre-test probability for perioperative M&M, reasonable to postpone an elective procedure for periop review.