PIG Notes March 31st 2022

• Cancellation due to respiratory issues
• EVAR and goals of care
• Insulin pump perioperative management
• New dilated cardiomyopathy, for lap chole

46-year-old for consideration of laparoscopic cholecystectomy

Background

• Chronic pain – ankle injury at work. In Cam Boot since November 2021. Awaiting chronic pain specialist input
• Complex PTSD
• Difficult social circumstances/isolation

Issues:

• HFREF – New diagnosis in January 2022
  • Dilated cardiomyopathy, EF 37%. Moderate functional MR
  • Admission with decompensated heart failure post-covid infection.
  • Alcohol-related, drinking 2 litres of wine per day
  • Commenced on optimal medical management: bisoprolol, Entresto (Sacubitril/Valsartan), spironolactone and furosemide. See figure below.
  • Symptoms stable – no orthopnoea/PND. Mild pitting ankle oedema.
  • DASI – 5 Met’s

Pharmacological management of HFrEF

MRA – mineralocorticoid antagonist. ARNI – angiotensin-receptor neprilysin inhibitor

• Cholelithiasis – recurrent biliary colic. No admissions or cholecystitis.
• Alcohol abuse – abstinent since January but currently struggling with this.

Discussion

• Cardiology meeting discussion with repeat echocardiogram
  • Some improvement in echo but not as much as expected 3 months post-event.
  • LV now mildly dilated, LVSF unchanged/slightly improved. MR mild.
  • Outpatient review with cardiologist required preoperatively
  • Ensure euvolemia and careful cardiac monitoring perioperatively
  • NT proBNP = 298. Borderline, suggestive of increased perioperative risk and therefore aids in decision-making with regards to perioperative monitoring and level of postoperative care.

• Alcohol abuse
  • Multiple significant contributors
  • Discussed options for support, patient keen to engage.

Plan:

• Await cardiologist review
• Aim for surgery with 3 months.

43-year-old lady for consideration of laparoscopy for investigation of endometriosis, pelvic pain, and menorrhagia

Issues:

• Type 1 DM, good glycaemic control
• IHD
  • STEMI in 2020. Post-partum.
  • LAD stenosis 90%. PCI to LAD,
  • DAPT for 12 months.
• HFrEF with global hypokinesis
  • Admission post PCI with APO but now stable on medical therapy
  • Excellent exercise tolerance
  • Regular cardiologist review
• MH
  • confirmed on Muscle biopsy
  • Previous trigger-free GA without issue

Discussion:

Management of Insulin Pump Perioperatively

• Current guidelines recommend liaison with endocrinologist perioperatively
• Endocrinologist letter:
  • Patient can adjust pump during the fasting period.
  • Preoperatively check BSL and Ketones. If BSL > 15mmol/L and/or ketones raised on arrival to hospital, postpone surgery and call the endocrinology registrar
  • Cease insulin pump pre-induction and commence IV insulin-dextrose infusion
  • Insulin infusion with IV dextrose to continue until she has tolerated one good meal and can self-manage pump.

Glucose monitoring

• Continuous glucose monitor can be used to monitor BSL in conjunction with regular capillary measurements
  • IV fluid administration may affect accuracy as can alter the composition of interstitial fluid
  • Manual finger prick glucometer should be done regularly.
  • Perioperative target = 6-12mmol/L
  • Evidence to suggest monitoring system may be affected by diathermy/EMI. (Note effects are uncertain, likely a warranty issue).
  • Therefore, best practice to monitor capillary glucose regularly even for shorter procedures
  • See article – https://doi.org/10.2337/dc20-2386

Plan

• Proceed to surgery
• First on list, trigger-free anaesthesia
• Management of insulin pump and continuous glucose monitor as per endocrine advice

78-year-old man for EVAR, 55mm AAA

Background:

• Nursing home resident
• Lung nodule – mild uptake on PET, uncertain aetiology. Under surveillance by respiratory physician. Not a candidate for surgery
• COPD. Ongoing smoker. 90PY. FEV1/FVC = 41%
• Hypertension and high cholesterol
  • Normal sestamibi 2021
• DHS – hip fracture, 2020. GA
• Incarcerated hernia repair under GA 2021

Issues:

• AAA – Incidental finding, Infra-renal. 5% annual rupture rate
• Wheelchair-bound, Severe OA both hips
  • Assistance with all ADL’s
• CVD, Cognitive impairment – mini cog 3

Discussion:

Clinic consultation with patient and son:

• Patient is keen to leave nursing home but has a reasonable quality of life which he enjoys.
  • High risk for further cognitive decline
  • Risk of mortality is more than risk of rupture – both theoretical
  • Clinic anaesthetist advised against proceeding; benefits of procedure greatly outweigh potential long-term risks. Patient uncertain regarding this decision. Capacity to consent has not been formally examined.
  • NSQIP surgical risk calculator showed a 24% risk of serious complication and a 12.4% risk of death.

Benefits vs Risks

• Consensus agreement with clinic anaesthetist.
• Life expectancy is limited at 78 years old with significant co-morbidities
• Patient is at risk of declining quality of life which he currently values

Where to from here?

• Should this conversation be continued over the phone or a repeat face to face consultation?
• Decision-making capacity uncertain – formal assessment needed.
• GP could consider geriatrician referral
• Daughter is NOK but was not in attendance. No POA/substitute decision maker.
• Important to note that declining this procedure based on perioperative risk would not preclude him from further surgeries e.g., hip-fracture surgery

Plan:

• Not for EVAR, letter to referring surgeon recommending conservative therapy
• Further meeting with family and clear documentation in notes required

GP to assist patient and family with advanced care planning

70-year-old for laparoscopic Bilateral Salpingo-Oophorectomy and ovarian cystectomy

Background

• CKD – stage 3
• Complex ovarian mass
• BMI 41

Issues

• Severe COPD
  • Ex-smoker 60 pack years
  • FEV1=0.6 (31%), FVC=1.45 (52%)
  • Has preventer but doesn’t use, Ventolin a few times per week
  • Oxygen saturations 95% at clinic
  • No formal diagnosis/respiratory physician review
• Decreased functional capacity, 4 MET’s
• Pulmonary hypertension
  • Previous admission for fluid overload/HFpEF in 2016
  • No PND/peripheral oedema
• In anaesthetic bay – described exertional angina and orthopnoea
  • uncertain history of NSTEMI.
  • Cardiologist review previously but hasn’t been seen for a while.
• Discussed with surgeon on day, cancer unlikely. Agreement to postpone for investigation and risk-stratification

Discussion

• Short notice patients in clinic due to covid cancellations and recovery
  • Imperative to discuss with proceduralist if any concerns
  • Patient was on gynae-oncology list, but not a cancer patient
  • Distance patient
• Review process for Respiratory Rapid Access Clinic currently underway by Dr Papeix. Recent meeting with respiratory physician revealed:
  • Role for some patients to have a RAC review perioperatively
  • Minimal optimization achievable in setting of stable COPD. Approximately 20% would have eosinophilic picture and would benefit from inhaled steroids
• Majority already on LAMA/LABA
• Inhaled steroids overused in community and main function is to decrease frequency of exacerbations
• Minimal role for inhaled steroids in reduction of perioperative risk
• Asthma – Asthma control questionnaire. Role for management of asthma perioperatively. Oral steroids take weeks to improve control and for those that qualify for leukotriene-receptor antagonists, months
• Cystic Fibrosis – regular review by specialist but should be seen preoperatively
• Interstitial lung disease – some therapies which can impact systemic inflammatory process. Can take weeks to see improvements
• Role for respiratory review in undifferentiated dyspnoea where cardiac cause has been excluded
• Discussed at cardiology meeting – referral to cardiologist in local area for review and likely stress cardiac imaging

Plan

• Postpone for 3 months
• Await cardiologist and respiratory review
• Follow-up in perioperative clinic

PIG Notes November 11th 2021

• Aspiration pneumonia, fundoplication
• Complex capacity issue
• Anaphylaxis and subsequent surgery
• ? Perioperative Cardiac Ix

45-year-old lady for hysterectomy 

Background

• Menorrhagia
• Smoker – cigarettes and marijuana
• Laparoscopic salpingectomy recently, no issues
• Ex-IVDU
• Ex heavy ETOH
• Very difficult social situation

Issues:

• Intermittent chest pain
  • Challenging history
  • Atypical and self-limiting
  • Weekly, Exacerbated by stress
  • DASI > 4 METs
  • Normal ECG, no other cardiac investigations
• Asthma
  • NYHA class 3 dyspnoea
  • Regular Ventolin use
  • No admissions or steroids
  • Unable to afford preventer
  • Normal spirometry
• Epilepsy
  • weekly seizures, improved from previous
  • GP managing as currently awaiting neurologist appt. 
• Menorrhagia
  • Letter from gynaecologist – try progesterone therapy first
  • Uncertain as to why has been listed for surgery
  • Hb 120, ferritin 36

Discussion

Optimisation

• Cardiac Stress Test indicated?
  • Difficult decision, low-risk surgery. 
  • Patient not keen for further investigations despite risks and benefits being outlined in clinic
  • GP has written medical certificate at patients request stating that chest pain is stress-induced and not angina-related.
• Respiratory consult
  • Stable asthma
  • Not compliant with preventer therapy – encouraged to do same

Plan:

• Discussion with GP regarding need for cardiac investigations
• Discuss with gynae surgeon – elucidate reason for procedure. 
• Smoking cessation
• Recommence asthma preventer
• Social work support

70-year-old man for Second shoulder surgery 

Background:

• Previous TSR – refractory hypotension intra-operatively
• No response to metaraminol
• Responded to small bolus and brief infusion of adrenaline
• No other features of anaphylaxis
• Surgery completed
• Well postoperatively

Issues

• Tryptases 7.3/10.3/5.4 – dynamic changes but not significant rise
• Immunologist opinion that dynamic changes in tryptase make it difficult to exclude mast cell activity
• Allergy testing – extensive tests performed including agents to which he had not been exposed
• Several mild skin reactions to propofol, vecuronium, chlorhexidine, and tranexamic acid.
• Nil reactions to other common allergens used on DOS
• Normal IgE levels specific to chlorhex, morphine, and latex
• Conclusion from testing – Avoid NMB used at time (rocuronium), use iodine instead of chlorhex. Avoid TXA if possible. Propofol most commonly irritant so safe to use.

Discussion:

• Difficult situation
• Non-allergic/Anaphylactoid – i.e., not an IgE mediated process? Not included in allergy testing 
• See attached BJA article (doi: 10.1016/j.bjae.2019.06.002) on perioperative anaphylaxis

Plan

• Proceed with surgery and follow immunologist advice
• Preoperative discussion with patient regarding above discussion

20-year-old lady for Removal of wisdom teeth

Previous cancellation on day of surgery as declining OT

Background:

• Ex-premature baby; 25 weeks
• Mild developmental delay
• Autism

Issues:

• Attended hospital on day of surgery with her father, declining OT, and premedication
• Previous traumatic experiences in theatre as a child, felt she was having medical procedures against her wishes.
• Patient stated she doesn’t have any dental pain, doesn’t need or want to have teeth extracted
• Father had signed consent form but is not official enduring guardian
• Procedure was cancelled on DOS in accordance with the patient’s wishes 

Discussion

• Formal assessment of capacity:
  • NSW health special disability referral team pathway
  • Temporary guardianship order granted. 
  • Lengthy process
• Father struggling with this issue and prefers not to become guardian in this instance

• No psychological or social support for those with PTSD to mitigate stressors of attending hospital/OT as there are for children.
• Consensus that even if patient doesn’t have legal capacity, it will be very difficult to carry out minor (non-life or limb-threatening procedures) if patient not willing.
• Premedication unlikely to improve situation as previously declined

Plan

• Consider pre-hospital premedication
• Preoperative psychology input
• Liaise with procedural anaesthetist

62-year-old lady for Laparoscopic Hiatus hernia repair /Fundoplication

Background

• Epilepsy 
• Right hemicolectomy – Iatrogenic Perforation post colonoscopy 
• Significant mental health conditions – Bipolar affective disorder, PTSD, anxiety
• Chronic back pain, known to HIPs. Using cannabis oil, no opioids.
• Fe-deficiency anaemia

Issues

• Symptomatic Hiatus Hernia/GORD/Oesophageal dysmotility
  • Recurrent aspiration pneumonia 
  • 5-6 admissions in last 2 years
  • Sleeps on bed wedge
  • Eating clear soups and fasting from 5pm.
• Moderate COPD:
  • Formal PFTs: FEV = 1.34 (55%) DLCO = 42%
  • FEV1 in clinic significantly decreased from previous; 0.82 (39%)
  • Clinically not dyspnoeic 
  • DASI 3.9 METs. Independent with ADL’s
• Pulmonary nodules – non-malignant, thought to be inflammatory

Discussion

Perioperative Optimisation

• Recent spirometry indicates pulmonary function has deteriorated
  • sequelae of recurrent aspiration pneumonia?
  • Clinically no change
  • Clinic spirometry – often difficult to obtain good technique and therefore, accurate results
  • Formal PFT’s would be useful in this circumstance though unlikely to change management
• Regular review by respiratory physician:
  • Optimised, LABA and 2 inhaled steroids
  • Concerned regarding recurrent aspirations and feels surgery should proceed 

Risk of postoperative pulmonary complications (PPC)

• ARISCAT score = 13.3%, intermediate risk of in-hospital PPC
• GUPTA – 13.7% risk of post-op pneumonia

Disposition

• Open vs lap, unusual to have to convert to open procedure
• If open, would need rectus sheath catheters and possible ICU 2
• ICU 3 suitable for laparoscopic procedure planned

Plan

• Formal respiratory function tests and discussion with physician if any change
• ICU 3
• Discuss with procedural anaesthetist