68 y/o F for Reverse total shoulder replacement

Background:

• BMI 60
• Diabetes :
  • HBAIC 7.8% (from 10.6)  -Improved control 
• CKD : eGFR 52
• HTN
• OSA- CPAP compliant
• Echo- moderate diastolic dysfunction
• Poor mobility – FASF, weekly physiotherapy and hydrotherapy
• DASI- Mets:3.63

Issues

• Exercise Tolerance reduced: SOB on arrival to clinic
• Poor diabetes control
• Opioid tolerant (30 BD oxycontin)
• High BMI

Discussion:

Proceed versus alternative therapy (Steroid injection/ Nerve blocks)

• Weight loss would assist pain and potentially avoid the need for surgery (note other shoulder becoming more problematic – ? due to FASF)
• Consideration of non-surgical management options for pain 
• Surgical team unaware of FASF use – ? will be able to use FASF after surgery, ? patient safe to mobilise without it

Plan

• Delay for 3 months
• Weight loss – Dietitian referral to free clinic 
• Contact GP re. iron replacement and GLP-1 antagonist (weight loss + DM optimisation)
• Exercise physiologist to optimise exercise tolerance and mobility – ? avoid need for FASF
• If surgery proceeds, would need ICU level 2 given risk of respiratory compromise with OSA and phrenic nerve block