89yo lady with recent episode of gallstone pancreatitis

Background

• Mild cognitive impairment, 22/30 on MOCA. Known to geriatrician. Living at home.
• Pancreatitis – 1 x episode due to ? thiazide diuretics, 2^nd episode with documented gallstones.
• HTN, controlled
• TIA
• OA
• Recurrent falls, mobilises with 4WW
• DASI METS 3.9

Issues

• Risk of POCD – Patient concerned about any possible cognitive decline. 

Discussion

• Further episodes of pancreatitis may lead to cognitive or functional decline
• Is there a less invasive operation possible (e.g some kind of stenting at ERCP). What would be the risks associated with any alternative procedures (e.g. failure, recurrence, sepsis, damage to surrounding structures etc)
• What is her ongoing risk of gallstone pancreatitis if she does nothing
• Is there any optimisation possible – known to geriatrician
• ? role for melatonin in prevention of postoperative delirium
  • Studies and MAs suggest benefit however heterogeneity in study interventions and outcomes assessed limits the robustness of the results. 
  • Possibly acts through restoration of sleep-wake cycles and direct anti-inflammatory actions.
  • Nb. Most studies excluded patients with known pre-existing cognitive issues or those on psychoactive medications (likely the highest risk patients) 

Plan

• Discuss with surgeon – update: no stent options since the stones would still have to pass through the pancrease where they may cause pancreatitis. Cannot quantify risk of further pancreatitis episodes. Recent literature suggests reasonable to conduct lap chole in extreme aged population. Ultimately, patient needs to weigh up the risks.
• Discuss with patient – update – patient unsure of which path to take. Rpt appointment made with surgeons for further discussion.
• If OT proceeds, for referral to acute inpatient geriatrics service to facilitate early geriatric co-management. See infographic below from the ASA Perioperative Brain Health Initiative. Available at https://www.asahq.org/brainhealthinitiative/tools/infographics

34yo lady, consult for consideration of stent change.

Background

• Complex urological history – multiple previous surgeries. Right PUJ obstruction and dense ureteric stricture. Previous failed laparoscopic pyeloplasty. Ureteric stent in situ since September 2022
• IHD – NSTEMI October 2022. Angiogram showed 2-vessel disease. PCI with DES to culprit LAD lesion. Left Circumflex 80% distal stenosis treated with medical therapy. On DAPT, recommended 12 months duration.
• IDDM – suboptimal glycaemic control, long-standing. Recently self-ceased oral hypoglycaemic agents and insulin. Random BGL today in clinic 23mmol/L.
• Chronic back pain – describes long-standing sciatica-like symptoms but some suspicion for intermittent claudication. GP has referred to neurosurgery.
• Current smoker – 30 pack years. Normal spirometry
• Complex social situation – childhood trauma. Currently undergoing significant stressors with her own children.

Issues

• Timing of procedure after PCI/NSTEMI
• Targets for optimisation

Discussion

• Aboriginal liaison officer possible role
• Timing of surgery – procedure needs to occur due to in situ stent therefore timing to be guided by cardiology and urology teams (ideally would wait 12 mths after AMI but not feasible here).

Plan

• Liaise with urologists regarding clopidogrel plans and timing of surgery
• Physician review for general medical optimisation
• Patient declining social/ALO involvement
• Surgery in a centre with PCI availability

42yo lady for Gastroscopy/colonoscopy/ polypectomy

Background:

• Congenital heart disease – single ventricle
  • pulmonary stenosis 
  • moderate pulmonary hypertension 
  • No cardiac surgery
  • Yearly cardiology review and echocardiogram
  • SpO2 70% in clinic – usual range 70-80% for patient
• Polycythemia
• Living independently, working. Goes to gym

Issues: 

• Palpitations – increasing over last few years.
  • Extensive cardiac investigations
  • Atrial ectopics – no intervention required.
  • Reports of increased palpitations recently – no syncope or associated symptoms
• Anxiety – significant around awareness of palpitations.
  • Seeing psychologist
• Functional capacity – 
  • Limited by NYHA class 2 dyspnoea 
  • DASI scored 18.7, Mets 5 
  • Discussion around accuracy of self-filling form as opposed to clinician questioning
• Positive FOBT in setting of melaena 
  • Strong FHx bowel cancer – sister Passed 1yr ago
  • Strong indication for testing
• Annual cardiology review due day after procedure 

Discussion:

Update from cardiologist:

• Patient has previously refused surgery for CHD and refuses all meds
• Appropriate to proceed to endoscopy.
• Tolerance of hypoxia advised during anaesthetic as not correctable

Anaesthetic techniques

• GA v. awake. 
• Patient expectation management key
• Would a cardiac anaesthetist have additional skills to offer if more major surgery required (e.g. bowel resection)? Unclear, for further discussion should the need arise.
• Should surgery be undertaken at PHTN centre (Pulmonary Hypertension Australia website lists RPA and St Vincent’s as PHTN centres). How does this differ from our service at JHH with a PHTN MDT?

Bowel prep plans

• Patient cognitively and mobility-wise able to manage bowel prep at home.

Plan:

• Proceed
• Bowel prep at home.
• Anaesthetist needs notification/call regarding case
• Cardiology Interest meeting – clarify PHTN centre v. JHH differences

PIG Notes May 11th 2023

• Frailty, MVR, PRB
• Severe COPD, lumbar laminectomy
• Colonoscopy v. TAVI
• Open AAA, high risk CPET
• Palliative vascular procedure

40yo male with severe comorbidities for femoral endarterectomy 

Background

• Severe central sleep apnoea. Previous postoperative respiratory arrest due to same. Home NIV (non compliant) 
• ESRD
  • Haemodialysis.
  • Non-adherent to fluid restriction – high volume fluid removal each session
  • Burnt his feet in the shower and did not realise for 3 days 
• HTN
• PVD with risk of tissue loss
• Peripheral neuropathy – multifactorial. Previous severe burns to feet from same.
• Epilepsy with occasional seizures due to non-adherence 
• AF on DOAC (to cease for 3 days) 

Issues

• Perioperative risks
  • Previously declined for parathyroid surgery due to perioperative risks

• Goals of care
  • Complex as this patient refuses or is non-adherent to therapeutic interventions 

Discussion

• Limb-threatening condition with significant impact on QoL – patient should have procedure

Plan

• Proceed with surgery
• Dialysis day before (wed) 
• To bring in CPAP despite adherence issues
• ICU level 2 

~75yo lady with incidental finding of 6.6cm juxta-renal AAA. Not obviously amenable to EVAR. 

Background

• Unprovoked DVT – warfarin 
• PMR – 2.5mg pred for  years 
• Independent, walks 1km/day 
• Driving license automatically revoked due to AAA size causing social isolation and loss of independence for patient

Issues

• Patient wishes
  • She understands the risks fully and wants to proceed open AAA
  • Very distressed by the threat of rupture and by her current loss of independence

• Cardiac function/exercise tolerance
  • TTE and sestamibi normal
  • CPET results stratify to high risk category:
    • Low AT 8.4ml/kg/min, low peak VO2 10ml/kg/min
    • Symptomatic with Dizziness and fatigue
    • HR peaked early then decreased throughout test (very abnormal) – ? AF
    • DBP decreased
    • Reviewed at CPET MDT – high risk candidate for open procedure

• Open v. EVAR
  • Potential for custom made EVAR graft however 12 weeks manufacturing time -> risk of rupture (10-20% annually) and longer time without independence preop.

Discussion

• Potential for prehab but challenging with transport issues
• What is her goal from the surgery? Avoid rupture vs to return to previous function. How does the latter goal align with likely outcomes from an open AAA. 
• Cardiologists suggest AF (if present) not optimizable because she does not require rate control. 
• How do we balance patient wishes against risks and potentially futile procedures?

Plan

• Psychological support offered through CPET MDT
• Holter monitor and cardiology follow up organised
• Discuss with surgeon re. EVAR

83M with + FOBT and CT abdo showing suspicious bowel thickening.

Background

• Known AS with recent progression of severity on TTE, PHTN (peak 73mmHg).
• Extreme SOB on minimal exertion.

Issues

• Timing of TAVI v. colonoscopy

Discussion

• Short duration of anticoagulation requirement after TAVI which will not preclude bowel resection (if indicated)
• Colonoscopy results will allow prognostication, dictating the urgency or necessity of the TAVI (e.g. operable lesion v. palliative pathway)

Plan

• Proceed to Colonoscopy

78year old lady with L4/5 canal stenosis causing radiculopathy (pain and numbness) without motor weakness or signs of upper motor neurone compromise. Requiring opioids and neuropathic agents. Significant impact on QoL. Some relief from steroid injects one side but not the other ?proceduralist inexperience.

Background

• Severe COPD 
  • Exacerbations x4 in last year requiring stress steroids and Abx  
  • Spiro: FEV1 34% 
  • SPO2 90% clinic with quiet air entry 
  • Heavy smoker
  • Appeared breathless at rest
• CVS: PPM for bradycardia
• Attended appointment in wheelchair due to leg pain + SOBOE
• MCOG 3/5 

Issues

• Perioperative risks
  • ARISCAT scoring – high risk of POPC https://www.mdcalc.com/calc/10022/ariscat-score-postoperative-pulmonary-complications#use-cases
  • NSQIP – high risk of functional decline 30% severe, 8% death, 24% delirium post op
  • BODE index suggests 80% mortality within 4 years (see Eur Respir J 2008; 32: 1269–1274 DOI: 10.1183/09031936.00138507)
  • Patient expressed that the periop risks were too great for her. Goals are to be at home with her growing family.
• Appropriateness of surgery?
• Alternatives to surgery?

Discussion

• What is natural history of disease? Will it progress to cauda equina syndrome or motor weakness?
• Comment from pain team: symptoms sound like nerve root irritation which has potential for functional rehabilitation, core strengthening, to improve pain and function.
• Non-relief of back pain from surgery is common

Plan

• Discuss with surgeons – natural history of disease?
• Consider surgical path if surgery is inevitable.
• GP to refer to respiratory physician (regardless of surgery) – can possibly optimise exacerbations although improvement/engagement may be limited if ongoing smoking
• Suggest referral for physical therapy
• Support for patient’s decision to decline surgery at this stage

Elderly, frail gentleman for gastroscopy and Colonoscopy – background of PR bleeding with supratherapeutic INR. Nil episodes since INR within appropriate range.

Background: 

• CVS: 
  • OOHCA 2018 with 4x stents 
  • Metallic MVR 2004
  • Severe TR
  • AF 
• Severe eczema + Grover’s disease (itchy rash) – recent course of prednisone 
• Resp: OSA with CPAP 

Issues

• CVS – Recent functional deterioration, low exercise tolerance ++  
• Anaemia – persistent. Iron replete

Discussion

• Perioperative Risk
  • High anaesthetic risk due to CVS morbidity
  • Physiologic stress of bowel prep and requirement for interruption of anticoagulation
• Goals of care
  • Low likelihood of positive finding as per proceduralist (probable small bowel angiodysplasia, nil lesions on CT colonography and previous normal gastroscopy)
• Potential for gastroscopy (without biopsies) without interruption to anticoagulation? 
• If further bleed with appropriate INR, would we consider greater need for scope? 
• ? patient optimized – recent deterioration ++ in exercise tolerance. Nil obvious signs of heart failure on examination. 
• Clinicians with longer term care of this patient may be better positioned to determine how procedure aligns with goals of care

Plan

Discuss with cardiology re optimisation and bridging requirements (if requiring biopsies)

PIG Notes May 18th 2023

• Pleural effusion and renal failure
• TSR and chronic pain
• Unexplained weight loss, cervical laminectomy
• Obesity, deconditioning, nephrectomy
• Cranial nerve palsies