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

PIG Notes November 4th 2021

• Ovarian mass, decompensated liver failure
• Frail, fumigating facial SCC
• Elderly patient, ? oesophagectomy
• Severe OSA, tonsillectomy (adult)
• ? Carcinoid

53 yo lady for EUA rectum/biopsy – rectal mass. Recent colonoscopy

Issues:

• Potential neuroendocrine disease secondary to rectal mass – flushing, tachycardia, and sweats
• PET-avid thyroid nodule as well.
• Note: Patient thought she was peri menopausal.

Discussion:

• Endocrine discussion – carcinoid? Chromograffin A – mildly elevated. Not significant and no increased risk of Carcinoid disease or syndrome as per endocrine and surgeon.
• TSH – low 0.16. ? hyperthyroid. T3 and T4 pending. Would that be a reasonable explanation?
• Any further tests required? Can we test to see if patient is menopausal – discuss with Gynae

Plan:

• Free T3/T4 – normal 
• FSH and LH – normal 
• Discussed with endocrine : no further investigation or management indicated. Unlikely menopausal. 
• Proceed to surgery. 

41 yo for tonsillectomy

Background

Severe OSA, AHI 107, normally on CPAP

Morbid obesity – 56

IDDM – new diagnosis after recent presentation with Hyperglycaemic hyperosmolar syndrome (HHS) requiring ICU

Issues and discussion

• ICU post-operatively?

Mixed central and obstructive sleep apnoea – higher risk as per literature and respiratory discussion.

Tonsillectomy in adults is painful. Opioids often required

• Patient had ICU bed booked in clinic by a senior consultant. Surgeon had indicated that ICU bed not required.
• Surgeon of the opinion that patients are usually much better post-operatively
• CPAP post airway surgery – usually ok post tonsils. Not post sinus surgery.
• Surgical preference on RFA is always helpful and if we are deviating from that it is helpful to communicate with surgeon. Note ICU beds are in demand at JHH, and patient may be cancelled or list delayed if no ICU bed available. 
• Children post-tonsillectomy often go to PICU. Evidence is growing to show that this is unnecessary, regardless of AHI

75 yo with oesophageal cancer

Background:

• HTN
• AF – CHADS-VASC 4
• Binge drinker
• Ex-smoker
• NIDDM
• Epilepsy – absence seizures

Discussion:

• BP in clinic – 192/70
• Discussed at CPET group – not taking medications as has no regular GP
• Spirometry: Mild airflow obstruction, post BD change 28%. Consistent with asthma.
• CPET – Peak VO2 low at 15.2ml/kg, AT 7.7ml/kg/min. T depression inferolaterally towards peak exercise.
• Maximal stress test: HRmax – 85% predicted. This patient reached 82% predicted, RER – 1.15. This patient – 1.12. RER (VCO2/VO2)
• Ventilatory reserve – MVV=FEV1x35, should have at least 20% reserve. Patient has encroached on his ventilatory reserve. HR also raised at this time which could suggest SV limitation. Note patient has not been taking bronchodilators.
• NAC – surgery planned for 8 weeks post NAC. Concern that patient will significantly decompensate with chemo
• Borderline – alcohol intake – unwilling to cut-down. Weight loss, non-compliant with medications
• Social issues – no car, may not be able to participate in prehab, from isolated area
• Prehab – multiple options. Dr Jen Mackney co-ordinates via CPET MDT and periop clinic. This patient would be better suited to a supervised program. 

Plan

• Restart antihypertensives and bronchodilators
• Formal stress imaging
• Prehab and re-test preoperatively before deciding if fit for surgery.

85 yo man for excision of large fungating SCC from face

Background

Nursing home resident – lived alone on a farm until recently. Entered nursing home post-cataract surgery as found to be not coping at home

Dementia

Prostate cancer

CABG 1997. No follow-up. Asymptomatic but doesn’t exercise much

DASI 3.9

Issues

• Very frail
• Large resection – PET scan shows invasion into skull bone and numerous surrounding structures. Lymph node involvement, no distant mets 
• Systolic Murmur
• Functional capacity very difficult to ascertain

Discussion:

• Surgical plan – palliative vs curative surgery and radiotherapy. 
• Curative surgery – Resectable but involves all inferotemporal fossa and teeth, will need neck dissection and free flap. May require exenteration of eye especially for curative intent. Long operation 8+ hours
• Palliative – will still require significant surgery and skin graft
• Surgeons feel curative us preferable for this patient. Likely die from maxillary artery bleed if cancer erodes into artery. 
• Has a mediastinal node – awaiting Endobronchial US guided biopsy in 4-6 weeks to determine if metastatic disease. IF metastatic, then not for surgery. 
• Family – further discussion required. Family discussion in clinic highlighted that patient will unlikely return to baseline. Patient and family were hoping that current nursing home admission was temporary.
• Stress imaging – unlikely to change management
• Echocardiogram – no evidence of heart failure but has a murmur. Could consider a BNP to give an indication of the contribution of valvopathy as has been recommended by cardiolgy in the past. 
• Post-operative delirium – very high risk given dementia.
• No baseline cognitive assessment. No regular GP

53 year old women for laparoscopy and removal of ovarian mass

Background

• Child pugh B liver cirrhosis secondary to hepatitis C
• Ovarian mass with raised CA125
• Seen in clinic in July 2021. Found to be in decompensated liver failure with ascites and right sided pleural effusion. 
• Discussed with surgeon. For 3/12 deferral only to optimize liver disease.

Issues

• Recent diagnosis – hepatitis C
• Decompensated liver failure
• Coagulation tests deranged 

Discussion

• Patient delayed 3 months – has completed treatment for Hepatitis C. Will have further pathology testing and liver ultrasound in follow up after surgery.
• Liver decompensation – treated with diuretics. Patient refused treatment with lactulose. Resolution of ascites and right sided pleural effusion
• Coagulation test derangement – common in liver disease, note that bleeding is related to abnormal anatomy (oesophageal varices, gastric/duodenal ulcers) and not necessarily coagulopathy. Current INR = 1.4, platelet count = 60.
• Is TEG useful to help guide management of bleeding? Discussion about it’s use before and/or during surgery.
• What treatment should be given for abnormal coagulation studies prior to surgery?
• Should she have regular Vitamin K?

Plan

• Patient discussed with surgeon as did not have date as yet. Surgeon was grateful for call as there was limited availability of operating time and this patient’s outcome may be affected by further delay to surgery. 
• Discussed with Haematology – they suggest that patient is unlikely to be coagulopathic. They state that recently released guidelines do not recommend platelet transfusion below levels of 50 in chronic liver disease who are not overtly bleeding, and that any FFP replacement is unlikely to significantly lower INR below 1.4 and not recommended in chronic liver disease (see DOI: 10.1111/jth.15562)
• Vitamin K seems low risk – especially given orally, although not recommended in guidelines attached. 
• TEG in cirrhosis – seems promising, although patients seem to have variable results. See extract from recent review, with conclusions below. 

PIG Notes October 28th 2021

• Breast cancer and severe eating disorder
• Partial gastrectomy, severe respiratory disease
• Hypothyroidism v. PPM
• Gynae surgery, DAPT and anticoagulant
• Update – Severe PD, spinal surgery

75-year-old lady for L4 and L5 laminectomy for bilateral leg pain. 

Retired anaesthetist

Issues:

• Parkinson’s – non-tremor dominant. Decreased mobility with rigidity, constipation, depression, and urinary incontinence. On Apomorphine infusion.
• Bulbar symptoms? Quiet voice and slurred speech on telephone. Denies dysphagia but describes frequent choking episodes, particularly at night.
• Recent aspiration pneumonia:
  • Awoke from sleep in middle of the night ‘choking’ 
  • 1-week hospital stay, requiring IV antibiotics. 
  • Treated for fluid overload. 
• TKR – 09/21. Uneventful spinal. Had been discharged a week when developed aspiration pneumonia.
• Frailty – significant decline in functional capacity over recent months. Requires care with all ADL’s, housebound. CFS = 7
• C1/C2 arthropathy – severe neck pain, referred for regional block. Pending.
• Distance patient
• Difficult to perform adequate clinical assessment via phone consult.

Update

• Discussed with neurologist: 
  • Disease severity and contribution of Parkinson’s to current immobility
  • Recent major surgery and readmission to hospital – choking episode related to Parkinson’s/opioids/both?
  • Suggestion of possible early cognitive decline?
  • Neurologist feels that pain is a significant issue but is certain that she has significantly deteriorated from a Parkinson’s perspective.
  • No documented any bulbar symptoms or cognitive decline but feels that these would be realistic symptoms of this type of Parkinson’s
  • He has organised a preoperative review
• Discussed with neurosurgeon:
  • Laminectomy will only help with back pain/sciatica in this case. 
  • He anticipates no improvement in mobility or urinary incontinence.
  • Happy to review in clinic and revisit indications and expected surgical outcomes

• Video consult 
  • Very helpful
  • Patient did not appear as frail as she sounded 
  • Updated patient and husband on neurosurgical and neurologist conversations
  • Husband expressing frustration at current level of immobility and encouraging patient to proceed with surgery when she was concerned regarding risks

Discussion

Timing of procedure

• 8 weeks post TKR – concerning regarding risk for DVT post TKR 
• Previous PE
• Discussed with neurosurgical team – they are not concerned. Predicting a non-instrumented, quick procedure with Clexane recommenced within 24 hours.
• Patients current level of immobility emphasised.

OSA?

• Describes regular ‘choking episodes’ at night
• BMI 33, no previous investigations for OSA. 
• STOPBANG – 5 ESS 7, HCO3 normal

Plan:

• Await input from neurologist regarding Parkinson’s progression.