R ocular surgery – transfer of eye muscles and eye botox for CN palsy 

Background: 

• Medullary Cavernoma
  • Recurrent Intracranial haemorrhage 
  • Multiple ICU admissions 
• Lone living – independent ADL’s 
  • Home supports 
• DASI 5 MET’s 

Issues: 

• LMN Facial Nerve palsy – forehead involvement
  • PEG in situ – can now tolerate a normal diet with no choking, or aspiration 
• Hoarse voice with pronounced dysphonia o Aetiology uncertain – trauma from ICU stay/repeated intubation 
  • Manifestation of cranial bleed? 
  • Previous grade 1 intubation – no record of trauma/difficulty 
  • No red flag symptoms – no dyspnoea, can lie flat, 
  • Vocal changes have been consistent since hospital admission. No deterioration 
  • Nasendoscopy – unilateral VC paralysis 
• Complex central sleep apnoea – uses CPAP 

Discussion: 

• Airway plan – ETT vs LMA
  • Unlikely to be suitable to for LMA 
  • Often lengthy 
  • May require muscle relaxation to facilitate muscle transfer 
• Surgical complexity – unknown.
  • Booked as day procedure 
  • Need to liaise with surgical team 

Plan:

• Discuss with surgeon 
• Post-op disposition:ICU 

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. 

84yo lady for cervical laminectomy. 

Background 

• Spinal canal stenosis – severe, numbness and weakness all 4 limbs, gait and balance affected, incontinence issues. 
• IHD – NSTEMI 2019, medically mx 
• HOCM – apical hypertrophy, nil LVOT, EF 65% 
• Dyslipidaemia 
• 4WW, assistance with ADLs 
• DASI 3.3 METS 

Issues: 

• Unexplained weight loss
  • 20% over 8 months 
  • Anorexia, decreased intake 
  • Concerning for occult malignancy 
• Surgeons + gastro consulted -> recommended CT/PET scan, endoscopies if anaemic 

Discussion: 

Should surgery proceed? 

• Non-elective procedure given imaging and clinical e/o myelopathy 
• Surgeon notes specify that improvement unlikely. Goal is to prevent further decline. 
• Timing of surgery relative to investigations? 
• Where possible, Ix should all be undertaken prior to surgery, as a palliative diagnosis may be made which would likely negate surgery 
• BMJ Best Practice guidelines have a summary regarding the patient with unintentional weight loss – See attached article 

Plan: 

• Add on TSH, HbA1c 
• Await imaging 
• Postpone surgical date 
• Liaise with surgeons regarding the above 
• Liaise with gastro team if anaemia identified – availability for urgent endoscopies 

86 yo M for shoulder replacement 

Background: 

• PPM – Symptomatic bradycardia 
• CKD stage 3. 
• Valvular disease, pulmonary hypertension 
• BMI 30 

Issues: 

• Chronic pain neck and shoulder pain – managed with pregabalin and oxycodone
  • Unable to tolerate NSAID’s due to renal impairment 
• Recent hospital admission
  • Deconditioned +++ 
  • Anaemia Hb 106, Ferritin high, Normal B12/folate, CRP pending, FOBT pending 
  • Delirium – attributed to urosepsis 
• Shoulder and arm pain exacerbation
  • Background of degenerative cervical spine and radiculopathy 
  • Shoulder pain worsening 
  • Steroid injection with little effect 
  • TSR being considered; Surgeons anticipating difficult and long procedure 

Discussion: 

Options for Pain Management 

• Non-operative treatment: no improvement with intra-articular steroid injections
  • Interventional pain options include repeat steroid injection, targeting suprascapular nerve 
• Pain may not be relieved by shoulder replacement
  • High-risk of perioperative complications, particularly delirium and cognitive decline 
• Anaemia investigations – possible slow recovery from recent illness
  • Differentials include Age related BM failure and occult loss 
  • Discuss with haematologist after checking CRP and Fe studies post urosepsis event tp exclude acute phase rise in ferritin 
  • Consider gastroenterologist opinion if no improvement 

Plan: 

• Delay operation 
• Consider non-operative treatment eg target suprascapular nerve 

76 yo lady for VATS pleurodesis – drainage pleural effusion 

Background 

• IDDM
  • IHD – CABG 2016, stents x2 since, o Angio 2020 all are occluded except 1 
  • PPM – 3rd degree HB o AF underlying rhythm 
  • Moderate MR 
  • Pulmonary hypertension 

Issues 

Large symptomatic pleural effusion – aetiology unknown

• Large symptomatic pleural effusion
  • Transudate 
  • Malignancy vs cardiac vs renal overload 
  • Recent Weight loss 
  • Failed conservative treatment – had pigtail catheter inserted and fluid drained. Talc down drain before removal. Immediate reaccumulation 
  • pro BNP > 45 000 
• ESRD – dialysis dependent o Anuric 
  • Fluid removal limited by limited by hypotension 
  • Hyperkalemia 

Discussion 

Proceed to surgery? 

• High risk patient – NSQUIP mortality 20% 
• Non-operative management has failed 

Opportunity for optimisation? 

• Renal team – any options for dialysis. Renal palliative care team involvement 
• cardiologist review and advice

Treating symptoms v. investigation of underlying cause

• Should she have malignancy workup?

Plan 

• Cardiologist referral –discuss with Dr Collins next week 
• Discuss with surgical team and renal team regarding requirement for further investigations/optimisation 
• Suggest referral to renal palliative care