Month June 2023

Cardiac symtoms prior to VATS

Gabrielle Morris 1 Comment

RUL presumed malignancy

Background

  • PET avid chest wall lesions – skin cancer
  • Schizophrenia 
  • COPD – normal spirometry, chest clear, nil recent exac

Issues 

  • Palpitations – frequent, long lasting, associated chest pain, diaphoresis, dizziness 
  • SOBOE 20m
  • New chest pain, lasting up to 10 mins, right sided radiating through to back, heavy sensation, at rest
  • DASI 3.7 mets 

Discussion

  • ?APID type tumour – secreting adrenalin / serotonin type substances 

Plan 

  • Stress echo and holter monitor 
  • Chase TSH and BP + HR records from GP

Lithium and elective CS

Gabrielle Morris

32yo lady G1P0, booked for elective CS. Recent diagnosis of congenital diaphragmatic hernia in the foetus. Highly stressful for mother. Mother on lithium.

Background

  • BPAD – On 900mg SR Li

Issues

  • Perioperaive lithium management
    • Psychiatrist recommended reducing dose to half throughout perioperative period
    • Patient would prefer to maintain current dose
    • Conflicting international and local guidelines about perioperative management

Discussion

  • Narrow therapeutic range for lithium 
  • Unknown (amongst our group) what the implications of perinatal physiology changes may be
  • Acknowlegement of maternal wishes in terms of risk of destabilization of mental health due to perinatal stress

Plan

  • ECG, EUC, TFTs
  • Discuss with neuropsych pharmacist
  • Update:
    • Discussed with neuropsych pharmacist and the consultant psychiatric representative for perinatal and infant mental health from community liaison psychiatry
    • Post-deliver physiology changes mean a return to pre-pregnancy levels is recommended after birth
    • High risk period for toxicity
    • Withhold dose the day before surgery
    • Lithium levels 8-12hrs post dose (regardless of daily or BD dosing) on day 1
    • Avoid dehydration, prioritise sleep
    • CL psych review while in hospital. Remain inpatient for 5/7
    • Breastfeeding contraindicated

Severe comorbidities, open ilio-inguinal surgery

Gabrielle Morris

Elderly patient for iliofemoral endarterectomy for QoL limiting claudication

Background

  • COPD – prev on home O2 post CAP, severe emphysema. SpO2 in clinic 89%, reduced to 84% with minor exertion
  • PVD – claud 20-50m
  • ETOH induced Cirrhosis, Grade 1 varices, bili 20, mildly decreased albumin, Plt 74
  • TTE – normal
  • Cardiac MIBI -ve

Issues

  • Method of anaesthesia – procedure usually under SAB + GA due to need for muscle relaxation around surgical space. 
  • Optimisation possible? – severe/critical COPD but recently stable 

Discussion

  • Acceptable platelet range in this setting? Proceduralist dependent. Advantages to neuraxial technique. Normal coags and negative bleeding history would provide some reassurance.

Plan

  • Check coags, FBC
  • Flag to procedural anaesthetist
  • Discuss with surgeons – how proximal into illiacs would procedure be? (i.e needing relaxation and therefore GA) given his severe COPD

HOCM, asbestosis before VATS

Gabrielle Morris

73yo male for R VATS and wedge resection for one of multiple lesions, presumed to be metastatic spread from unknown primary

Background

  • Partial gastrectomy ’04 for cancer
  • Oesophagectomy ’14 for cancer, subsequent strictures requiring dilatations 
  • Bladder Ca – diathermy based treatment, now under surveillance
  • HOCM w/ ASM + LVOTO, TTE 2022 gradient stable 39/15
  • IHD – minor L main disease, 70% LAD proximal lesion, + aneurysm, minor LCx, 40% RCA -> medically managed
  • Asbestosis – pleural plaques and coarse fibrosis R lung
  • Recent GAs well tolerated
  • DASI 6 METS

Issues

  • Long QT on clinic ECG – Nil obvious culprate medications, asymptomatic, 480ms
  • BSL 3.1 in clinic – nil hx or symptoms
  • Perioperative risk – RCRI class 3

Discussion

  • What is the primary cancer – Multiple previous cancers although reasonably distant. Tissue diagnosis needed for further oncology treatment
  • Low BSL in clinic – endocrine suggested morning cortisol and HbA1c
  • Overall co-morbidities, while significant, are stable. Reassured by good exercise tolerance and history of daily purposeful exercise.

Plan

  • For early morning cortisol, HBa1c, CMP, EUC
  • Proceed to OT
  • Warning note for HOCM

Suitability for EVAR?

Gabrielle Morris

62yo male with infrarenal 50mm AAA and bilateral CIA aneurysms

Background

  • STOPBANG 5, ESS 6 (patient attributes elevated ESS to recent stress and poor sleep)
  • DASI 8 METS 
  • Quit smoking 8 months ago 
  • Likely COPD – nil exac/symptoms/LRTI but spirometry in clinic showed FEV1 42%, ratio 0.53

Issues

  • Optimisation required or possible?

Discussion

  • Ideal not to have open procedure if able given likely moderately severe COPD
  • If open procedure would need CPET to further quantify risk and targets for optimization (cardiac or respirartory)
  • Conversion from endovascular too open on the day of procedure is rare
  • Suitable to proceed to EVAR without further optimization/delay

Plan

  • Proceed to EVAR

Hemicolectomy – prehabilitation?

Gabrielle Morris

70yo lady with ascending colon cancer.

Background

  • Mild OSA – nil rx
  • T2DM on insulin, Hba1c 8.4
  • Guillan Barre / CIDP – pred 6mg / day + IVIG monthly
  • Secondary adrenal insufficiency
  • Uses 4WW, CFS 3
  • Spiro and ECG normal
  • Iron replete, not anaemic

Issues

  • For prehabilitation?

Discussion

  • Lap vs open risks NSQIP – long term functional decline high for both ~70%, open much higher risk of serious complications, risk of death ~1% for lap, 3.5% for open
  •  Risks elevated by falls hx, chronic steroid use, SOBOE
  • Would benefit from prehab. Patient motivated to reduce risks where possible as reluctant ++ to incur any loss to independence/function

Plan

  • Discuss with prehab coordinator
  • Discuss with surgeon – ? appropriate time frame for delay

Spinal surgery, severe comorbidities

Gabrielle Morris

56yo female. Large disc bulge at L3/4. Radiculopathy. Nil cauda equina

Background

  • BMI 47
  • IHD – prev CABG (angio ’22 graft to OM occluded, moderate disease otherwise) w/ occaisional angina for medical management due to challenging angiography (patient intolerance)
  • T2DM on insulin, poorly controlled
  • Graves Dx
  • CKD eGFR ~ 45
  • CVA – balance and slurred speech remain
  • Depression
  • Legally blind
  • PTSD
  • Chronic thrombocytopenia, plt ~100
  • Full assistance w/ ADLs, living in group home, consent for self
  • Labile BP control – hypotension/hypertension, polypharmacy
  • Vapes, ex-smoker, distant asthma 

Issues

  • ? surgery indicated – main complaint in clinic and with carer was of back pain
  • ? able to physically prehabilitate
  • Goals of surgery? – pain v. functional improvement, likelihood of either?
  • Multiple unoptimized comorbidities
    • ? OHS (HCO3 mildly elevated, previously “slow to wake” after GA in 2021)
    • Poor diabetes control
    • Ongoing vaping
    • BMI 47

Discussion

  • Perioperative risk prediction can be challenging in patients like this whereby risk scoring tools may under-estimate risk
  • Would benefit from a physician to provide oversite of multiple organ systems and rationalize medications, rather than clinicians acting in silos. 
  • ? can have a “rehab” direct admission from an outpatient setting
  • Shared decision making  challenging when patient expectations around surgery outcomes are very concrete
  • Our traditional prehab models would not be appropriate due to this patient’s existing severe disabilities and needs.

Plan

  • Discuss with neurosurgeon – ? surgery indicated, ? risk if surgery postponed/cancelled
  • Ideally physician holistic management – will d/w endocrinologist
  • Explore rehab or cardiac rehab options
  • Investigation and management of ? OHS/severe OSA
  • Discuss with GP 

Myotonic dystrophy and large volume botox

Gabrielle Morris

37yo hysterectomy + hernia repair  multidisciplinary surgery involving gynae/gen surg

Background: 

  • Fibroid uterus, significant adhesions, previous failed surgery (unable to access the uterus)
  • Myotonic dystrophy
    • Reflux ++, slurred speech and dysphagia
    • Normal TTE and PFTs
  • Smoker

Issues:

  • Large Botox dose in context of myotonic dystrophy
    • Neurologist concerned with dose and potential for systemic absorption and prolonged exacerbation of muscular issues
    • Surgeon feels the high dose botox is essential to success of the procedure

Discussion:

  • Botox use in this setting
    • Injected into abdominal musculature
    • Takes 2-3 weeks for full response
    • Nil evidence/ literature around high dose botox dose in muscular dystrophy
    • Systemic absorption – risk of headaches, fever, HTN, generalized weakness, dysphagia, subsequent aspiration)

Plan:

  • Await further MDT planning between neurology and surgeons
  • ? reduced botox dose may be possible