New dilated cardiomyopathy, 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.

Insulin pump periop Mx

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

Plan

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

EVAR and goals of care

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

Cancellation due to respiratory issues

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

? 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

Anaphylaxis and subsequent surgery

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
Diagram

Description automatically generated

Plan

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

Complex capacity issue

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

Aspiration pneumonia, fundoplication

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