63yo male for removal of L3/4 hardware, L1/2 and L2/3 extreme lateral interbody fusion, posterior fixation T10 – pelvis. Multiple previous surgeries. Severe pain and dysfunction.

Background

• Myasthenia gravis
  • Bulbar symptoms, swallowing difficulty, fatigues with mobilization
  • Relapse in 2019 when steroids weaned below 30mg/d pred.
  • No spirometry available
• IHD
  • Angiogram 2019 – 40% mid-LAD stenosis (performed for atypical chest pain)
  • TTE – nil major abnormalities
• HTN & Dyslipidaemia

Issues and discussion:

• Should surgery proceed?
  • Reason for OT unclear during meeting.
  • High dose steroids -> concerns about bone quality and wound healing

• Further myocardial perfusion imaging?
  • 40% mid LAD lesion previously.
  • Low exercise tolerance due to MG and spinal issues, unable to quantify
  • Will need to cease aspirin perioperatively
  • Unlikely to change management.

• Cell salvage?
  • Nil obvious contraindications
  • With multi-level, long duration spinal surgery patient seems at high risk of significant bleeding.

• Level of postop care?
  • Preoperative lung function studies required
  • Factors predictive of postop MG crisis and requirement for postop vent (UpToDate)
    • Vital capacity <2 
    • Duration of MG greater than 6yrs
    • Pyridostigmine dose > 750mg/d
    • History of chronic pulmonary disease
    • Preoperative bulbar symptoms
    • History of myasthenic crisis
    • Intraoperative blood loss > 1000ml
    • Serum anti-acetylcholine receptor antibody >100nmol/ml
    • More pronounced decremental response (18-20%) on low frequency repetitive nerve stimulation.

Plan

• ICU level pending lung function studies
• Discussed with surgeons.
  • If cell salvage is feasible/required – awaiting response
  • Indication for surgery and high-risk nature of patient – extensive discussions about this patient at spinal MDT. Two surgeons involved in case. Aware of the risks. Surgery felt to be necessary.
• For discussion with cardiologist – requirement for stress imaging, and if postoperative ECG or troponin screening indicated.

66yo male for colonoscopy for polypectomy. 

Background

• Kartagener’s Syndrome
  • Bronchiectasis
    • Chronic SOB, ok on flat
    • FEV1 1.65 (50%), FVC 2.71 (63%) ratio 61% TLCO 54%
  • Situs inversus totalis
• IHD
• HTN & Dyslipidaemia

Issues

• 2019 critical illness
  • Life-threatening pulmonary haemorrhage
  • Failed intubation due to bleeding -> surgical cricothyroidotomy
  • 2/12 ICU stay, 17 days ECMO, DVT, IVC filter.
  • Multiple tracheal/bronchial clot retrievals and bronchial artery embolization.
• Recent Colonoscopy/ICU stay
  • Failed colonoscopy in private hospital due to difficulty passing scope. 
  • Patient reported anaesthesia complication and ICU stay post-procedure 
  • Anaesthetic chart – THRIVE and sedation, nil concerns
  • ICU d/c summary – precautionary admission, nil adverse events. 
     

Discussion

• What is Kartagener’s Syndrome?
  • Autosomal recessive, multiple possible genetic pathways known, some unidentified.
  • Primary ciliary dyskinesia leads to:
    • Neonatal distress syndrome
    • Frequent sinus and middle ear infections, hearing loss
    • Frequent resp infections, leading to bronchiectasis
    • Infertility
  • Situs inversus totalis (but organs unaffected in other ways)

Plan

• Proceed to colonoscopy
• Suggest right lateral position to aid scope passage. 
• If more major surgery required consider pulmonary rehab, nutrition optimization and respiratory review for bronchiectasis.

PIG Notes October 14th 2021

• Marfans and cardiac decompensation
• EVAR after prehabilitation
• EVAR v Open AAA
• Severe PD, spinal surgery

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

Background

• Retired Anaesthetist
• IHD – AMI 1997, recent angiogram normal, echo shows posterior RWMA and normal LVEF
• Paroxysmal AF – apixaban and diltiazem
• PE 2020 
• Peripheral neuropathy – chronic, affecting both feet.
• BMI 33

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. 
  • Commenced on Domperidone with nil further choking episodes.
• TKR – 09/21. Uneventful spinal. Had been discharged a week when developed aspiration. Unable to complete rehabilitation due to pneumonia.
• Frailty – significant decline in functional capacity over recent months. Requires care with all ADL’s, currently unable to stand unaided, housebound. CFS = 7
• C1/C2 arthropathy – severe neck pain, referred for regional block

Discussion

Optimisation

• Frailty and immobility – these are multi-factorial issues. Uncertain if optimisable based on telephone consult.
• Currently re-engaging with physiotherapist to perform rehabilitation for TKR
• Cardiologist review and echo pending

Perioperative risk

• Risks discussed with patient including death, serious complications, and discharge to nursing home. Understands and is keen to proceed. 
• Previously unaware of perioperative risks and thought surgery could be done under local/regional.
• Suggestion of possible early cognitive decline?
• Patient feels that a nursing home admission is inevitable and if she can delay that then she has nothing to lose
• Immobility and urinary incontinence are main factors affecting QoL – these are unlikely to be resolved by lumbar spine surgery. 
• Very difficult to make a decision without clinical assessment. 

Timing of procedure

• Recent major surgery and readmission to hospital – choking episode related to Parkinson’s/opioids/both?
• Discuss with neurologist regarding disease severity and contribution of Parkinson’s to current immobility
• 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

Plan:

• Liaise with neurologist regarding frailty/immobility
• Face to face or video-conference appointment at perioperative clinic
• Neurosurgical review preoperatively 

75-year-old man for assessment of open AAA Repair vs EVAR

Background:

• 5.5cm AAA, asymptomatic
• COPD – mild, no admissions. 38 pack year smoking history.
• Lumbar spine fusion
• Graves’ Disease

Issues:

• IHD – angiogram 03/21 shows moderate non-obstructive CAD and normal LV systolic function. Medical therapy only
• Bilateral foot trauma – work injury many years ago. Multiple surgeries
• DASI 5.3 MET’s
• Walks slowly with 4WW due to foot injuries but keeps active, plays lawn bowls.

CPET:

• Normal spirometry, TLCO 78%
• Near-maximal test: RER 1.05 and HRmax 122bpm (82% predicted)
• Test ceased due to knee pain and anxiety
• Peak VO2 = 14.6ml/kg/min (61% pred), AT 10.3ml/kg/min
• Nadir VE/VCO2 elevated at 41.1
• HRR 6bpm

Discussion:

Open vs Endovascular

• Consensus that an endovascular approach is preferred in this case
• Age is a significant limiting factor to open AAA surgery in this patient
• Discussed with the surgeon and they are keen to proceed with EVAR 
• Ultimately it is a surgical decision, however they value our collaboration in these complex patients
• CPET can help guide this decision-making 

CPET

• Performed well on the bicycle
• Limited by anxiety – elevated nadir VE/VCO2 and low CO2 are indicative of hyperventilation
• Useful test in this case as patient unable to walk any distance, easy to underestimate functional capacity

Rehabilitation post-procedure

• Unlikely to be required for EVAR
• Bicycle-based rehabilitation available at JHH and would be beneficial to this patient

Plan

• Prehabilitation with cycle-based approach
• Proceed to EVAR

67-year-old man for re-consideration of EVAR

Background:

• 5.5cm infra-renal AAA 
• Previous perioperative assessment and CPET for this procedure
• Deemed too high risk based on CPET results
• Progress over last 6/12;
  • Optimised from cardiac perspective, has commenced Entresto and fluid balance improved
  • Commenced a daily exercise program 
  • 30 minutes daily on treadmill at 3.6km/hr
  • DASI 5.6 MET’s
  • 14kg weight loss

Issues:

• IHD
  • Inferior MI 2008. Multiple stents to distal RCA 90% stenosis
  • Infrequent episodes of stable angina. On maximal medical therapy
  • SESTAMIBI – large, fixed perfusion defect in anterior wall with no reversibility demonstrated
• HFrEF – 49%. Hypokinesis of inferior and posterior walls. Moderate Pulmonary hypertension, Increased LV filling pressures.
• NIDDM – HbA1c = 6.7%
• BMI 45, after recent 14kg weight loss
• Severe OSA/OHS
  • compliant with CPAP. AHI = 97, SpO2 = 94% RA, HCO3 = 28
  • AHI reduced to 1 with CPAP however pressures inadequate and patient reluctant to increase. 
  • SpO2 82% overnight with CPAP
• Asthma/COPD – post-BD FEV1 = 2.47 (84%), FVC = 4.2 (112%), DLCO = 67%
• ICU admission 2021 with PR bleeding and type II respiratory failure requiring NIV

CPET:

1^st CPET – April 2021

• Sub-maximal test
• Stopped after 2 minutes of cycling due to hypertension (SBP>180 as per AAA protocol)
• Excessive ventilatory response – as demonstrated by VE/VO2 slope

• CPET MDT advised that patient was not a suitable candidate for any surgery. 
• Recommended prehabilitation

2^nd CPET – October 202

• Sub-maximal test – RER 1.05                                         
• Stopped due to SBP exceeding 200mmHg 
• Peak VO2 12.2ml/kg/min
• AT 1.5L/min or 9.2ml/kg/min
• Nadir VE/VCO2 34.8 (using actual body weight)
• HRR 7bpm
• VE/V02 graph for second test:

Discussion:

Optimisation

• CPET results reassuring that patient has been optimised
• Symptomatic HF treated – can now lie flat, previous orthopnoea
• Exercise also beneficial physically and psychologically in this case
• Remains a high-risk patient, RCRI 3, NSQIP risk of death 2%, cardiac complication 3.5%, and serious complication 15%.
• Patient and family understand and are accepting of risks
• Discussed with surgeon – surgery carries prognostic and QoL value even if life-expectancy limited.

CPET

• Near-maximal test and values for peak VO2 and AT obtained on recent CPET
• Retrospective data indicates poor long-term prognosis and life-expectancy based on inability to complete the test. See doi:10.1093/bja/aet193
• Results are based on actual body weight and not modified for ideal body weight.
• Maximal SBP values pre-determined in conjunction with vascular surgeon in cases of AAA to minimise risk to patient.

Plan:

• Proceed to EVAR

76-year-old man for excision and reconstruction of right tibio-peroneal trunk, posterior tibial and peroneal aneurysms

Background

• Marfan-like syndrome – dilated aortic root, aneurysms, high-arched palate
• AF – apixaban and metoprolol
• OSA – compliant with CPAP
• CVA – right MCA in 2019. Residual Left hemiparesis
• Monoclonal gammopathy – surveillance

Issues

Type A aortic dissection  

• AVR and ascending arch repair in 2005
• Known residual aneurysm
• Aortic Root and Ascending aortic aneurysm increasing in size – reviewed by CTS and deemed unsuitable for further surgery. High complexity and multiple co-morbidities

Exertional dyspnoea

• Increasing in severity over last 7/12
• NYHA class 2
• Decreased exercise tolerance – 3.6 MET’s. Limited by dyspnoea
• No orthopnoea, PND, angina.
• Overtly fluid-overloaded with pitting oedema to both knees at clinic
• Admission in March with Dyspnoea – treated for Strep Viridans endocarditis
• ECHO/TOE – no evidence of endocarditis, Severely Dilated ascending aortic aneurysm (75mm), severely dilated AR (49mm), Moderate RA dilation, severe LA Dilation, LV and RV function normal.
• No regular cardiology follow-up

Lower Limb Aneurysms

• Asymptomatic
• Risk of rupture requiring emergency intervention
• Previous superior gluteal artery aneurysm rupture requiring repair with glue after failed embolization
• Option for surveillance

Discussion

Optimisation

• Current fluid overload concerning
• Cardiology review and optimisation of therapy required preoperatively
• Patient feels not at best baseline and keen to wait until cardiology review
• Surgery not time-critical

Conduct of anaesthesia

• Surgery will be long and complex
• GA recommended to provide optimal surgical conditions and minimise physiological stress response
• Spinal discussed however consensus that haemodynamic changes more difficult to control and surgery will require patient to lie very still for prolonged period.

Plan

• Cardiology review preoperatively
• Postpone surgery for 3 months

PIG Notes October 7th 2021

• Hysterectomy, severe cardiomyopathy
• AAA v. bowel cancer
• Perioperative Mx of Latent TB
• Ix of syncope prior to TKR
• Semi-urgent minor surgery, recent PCI

83yo male for cystoscopy and stent exchange due to chronic obstruction from uroepithelial carcinoma.

Background:

• Uroepithelial carcinoma
• PVD
• Impaired glucose tolerance
• AF. On apixaban.
• PPM for CHB (99% paced, underlying AF).
• HTN
• Dyslipidaemia

Issues:

• Recent PCI 
  • Type 2 MI Post-operatively after stent insertion
  • Ongoing intermittent chest pain last 6/12
  • PCI + rotablation for severe ostial RCA stenosis. 3/52 ago
  • For lifelong clopidogrel and apixaban.
  • Ureteric stent now 7/12 old, urologists keen ++ to replace

Discussion

Ideal timing of surgery?

• Discussed with treating cardiologist: happy to proceed 4-6 weeks post-PCI
• Requests to continue clopidogrel perioperatively. 
• Discussed with surgeon – happy with plan

Communication in the perioperative clinic

• Much time spent attempting to phone proceduralists and clinicians, they are often busy/scrubbed and then call back when we are with another patient 
• Email often a more effective tool – ability to CC all relevant clinicians and the HNELHD-JHHPeriopnurse@health.nsw.gov.au perioperative nurse address. 
• Provides a paper-trail of communication. Encourages multidisciplinary engagement. 
• Clinician email addresses usually available on their letterhead/website. 
• The urology registrars are setting up an email address to allow us to create a bank of patients for them to ask their consultants about on a regular basis. 

Cardiac Investigations in this patient post initial Type 2 MI

• Interestingly this patient had a sestamibi which showed ‘no major area of inducible ischaemia’ and that patient had no chest pain throughout the protocol. 
• Note that the stress ECG component of the test is difficult to interpret in the present of Ventricular-pacing. 
• See article on non-invasive cardiac stress testing (http://dx.doi.org/10.1136/heartjnl-2015-307764).)

80yo man for L TKR. 

Issues:

• Episode of LOC several years ago
• Isolated event. Nil seizure-like features.
• Witnessed by family members
• Extensive review by neurologist – EEG showed prominent epileptiform features in the temporal lobe which were reproducible on repeat testing. 
• EEG abnormalities resolved with commencement of Levetiracetam. 

• Bifascicular block on ECG, HR 59, no cardiologist review

Discussion

Should we be concerned about a cardiac cause for his LOC?

• Reassuring features:
  • One distant episode. 
  • Now treated for epilepsy. No further episodes.
  • EEG showed a gross abnormality and repeat EEG after treatment was normal.
• Concerning features:
  • Episode doesn’t really sound like a seizure. Sounds more cardiac in origin.
• Unlikely that a cardiologist be interested in one episode of LOC
• Holter = low risk study however likely wasted resource and burdensome to patient 

Plan:

• Proceed with surgery without further investigations.