Author Gabrielle Morris
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
- 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
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
PIG Notes November 11th 2021
? 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
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