58 yo F with renal mass → renal clear cell carcinoma and increasing in size 

Background 

1. Goitre → T3/4 normal and TSH suppressed. 
2. OSA – CPAP
3. AF o SVT/rAF post induction previously 
4. HFpEF 

Issues: 

• Physical deconditioning
  • BMI 46 
  • Mobilises with wheelchair 
• Current smoker 
• Complicated perioperative course – Breast WLE 2023. Poor wound healing post excision and infection. Required re-intubation and ICU post-operatively 
• Multiple visits to perioperative clinic – decision not to proceed to surgery made by 2 senior anaesthetists based on significant co-morbidities.
  • Recent Cystoscopy and RPG/lithotripsy for renal calculus – uneventful surgery
  • Request for surgery re-submitted 

Discussion 

Perioperative Optimisation 

• Minimal changes so far with lifestyle modification – obesity, smoking 
• Recommendation not to proceed is not preclusive 
• Patient has been extensively counselled on perioperative risk and wishes to proceed. 
• Issue now is optimisation and prevention of post-operative complications – biggest risk PPC 
• Risk factors should be re-addressed with the new incentive of a surgery date
  • Weight loss – consider addition of GLP-1 analogue 
  • Smoking cessation – coaching previously offered, consider Champix? 
  • Prehabiliation 

Plan: 

• Metabolic clinic referral 
• Prehabilitation 
• Post op disposition: CPAP, HDU – do not start without HDU bed confirmed given previous extubation failure.