Author Gabrielle Morris
Multiple comorbidities, sinus surgery
57-year-old lady for septal reconstruction, bilateral inferior turbinectomy, FESS, radical middle meatal antrostomy
Background:
- Chronic sinusitis, pain, and sinus infections
- Asthma/COPD – no admissions, regular respiratory review
- Pulmonary nodules – under surveillance
- Ex-smoker
- Sjogrens syndrome – no DMARDs/steroids
- Renal cell carcinoma – nephrectomy 2006
- Thyroid nodule/MNG
- Fibromyalgia and chronic back/neck pain
Issues:
- BMI 48.
- Severe mixed obstructive and central sleep apnoea:
- Compliant with CPAP
- Recent re-titration of therapy due to 20kg weight-gain
- Nasal mask, will not be able to use post-operatively
- IDDM:
- Longstanding suboptimal glycaemic control
- HbA1c >11% at clinic, Postponed for optimization
- Endocrinologist review – commenced SGLT2 inhibitor and new insulin regime
- Recent cervical fusion:
- Reports uneventful perioperative course
- 4-day ICU stay for monitoring and CPAP
- Good range of neck movement
Discussion:
- Perioperative use of CPAP with nasal/sinus surgery
- Will have nasal packs in-situ
- Unlikely that ENT team will allow CPAP use in the immediate postoperative period
- Tolerates full face mask – will bring to hospital
- HbA1c now 8.7%, unlikely to improve further – not a barrier to this procedure
- Disposition – will require ICU post-op
Plan:
- Discuss with surgical team – long delay between booking and ready for care due to optimisation and Covid delays
- ICU 2 post-operatively
CPET before major urological surgery
67-year-old man for consultation. Referred by CPET team due to, sub-optimal test.
Background
- NIDDM – normal HbA1c. single agent. No complications
- Hypertension and hypercholesterolaemia
Issues
- Muscle-invasive bladder cancer – for NAC then surgery
- CPET – impaired cardio-respiratory function (pre-NAC)
- Max Test – HRmax – 92%, RER 1.22
- Peak vo2 15.2ml/kg/min AT 9.7ml/kg/min, nadir VE/VCO2 44.1
- HRR – 3bpm
- O2 pulse and HR rose appropriately until workload of 45 watts then plateaued; indicating a limitation in stroke volume
- Limited by leg pain/fatigue.
- No chest pain, desaturation, or ischaemic ECG changes.
- DASI 6.7 METs
- Deconditioned, rarely exercises. Previously been walking regularly with NDIS worker but ceased due to covid.
- Schizo-affective disorder
- stable on current therapy for 20 years
- Patient concerned that being in hospital could precipitate a relapse.
- Expressing concerns regarding ileal conduit
Discussion
- CPET results place patient in high-risk category for major surgery.
- Raised nadir VE/Vco2 indicates impairment in ventilatory efficiency – normal spirometry therefore possible cardiac cause?
- HRR less than 12 is also an indicator of higher risk for perioperative m&m
- RCRI = 1
- NSQIP – above average risk for cardiac, respiratory, and renal complications.
- Patient discussion – understands risks. Motivated to exercise. Remains uncertain if wants to proceed with surgery, will revisit issues with surgeon and urology CNC.
- Echocardiogram considered – no clinical indication. Should we perform based on CPET?
- CPET results are significant in this patient but form one aspect of the perioperative assessment. Not in keeping with clinical picture, therefore further consideration required.
Plan
- For further discussion at CPET MDT
- Prehabilitation – funding is possible via NDIS pathway
- Likely re-test post NAC and prehab
CPET before oesophageal cancer
61-year-old man Oesophageal cancer for consideration of Oesophagectomy
Background:
- Morbid obesity – BMI 35
- Asthma – no admissions, daily salbutamol
- Distant ex-smoker
- NIDDM – single agent
- Hypertension and hypercholesterolaemia
- Main carer for wife (chronic back pain)
Issues:
- Distal Oesophageal adenocarcinoma. T3N0
- Currently undergoing NAC with a view to trimodal therapy
- Multiple recent admissions – NG feeding, pancytopenia, and tachycardia
- CPET:
- Max test: HR =94% predicted RER=1.3 HRR = 7bpm
- peak vo2 = 9.8, AT = 5.1ml/kg/min, VE/VCO2 = 38
- High-risk category for major surgery – see departmental guideline below
- HR trajectory high, normal slope. Frequent finding in upper GI cancers
- Spirometry – mild obstructive defect
- Decreased fitness and deconditioning thought to be causative factors for poor CPET result
- VO2 and AT impacted by obesity as measured in ml/kg/min
- Perioperative clinic:
- wheelchair bound due to gout, normally walks with 4WW.
- 3.6 METs on DASI
- Normal Hb 125, Albumin 35, Troponin 4, HbA1c 5.4.
- Sinus tachycardia – 100bpm
- Extensive discussion with patient and wife regarding potential complications and high-risk nature of this surgery for him. Understands and is motivated to proceed, wants to continue to care for wife for as long as possible.
Discussion
- Extremely high-risk surgical candidate, warrants further discussion after NAC and prehab
- Decompensating with NAC – unlikely that we will improve fitness during this period. Aim is to to maintain current level of fitness with light exercise. Attempt to improve fitness post-chemo and pre-surgery, usually with HITT-training.
- Young patient
- Sestamibi organised – DASI < 4 METs and multiple cardiac risk factors. Abnormal test may add to the discussion in future.
Plan:
- Sestamibi
- Prehabilitation and physio during NAC
- Re-test CPET post-NAC
- Surgical review in interim
Perioperative anaemia
73-year-old man for Right laparoscopic adrenalectomy
Background:
- Large adrenal adenoma – phaeochromocytoma excluded after extensive investigation
- Cushing’s
- Hypertension and high cholesterol
- DASI 6.2 METs
Issues:
- New ejection systolic murmur and RBBB noted in clinic
- Echo – severe AS.
- Exertional dyspnoea after 30 minutes of mowing. No angina
- Surgery postponed for Cardiothoracic review
- AVR with tissue valve 6 months ago, no anticoagulants
- Recent admission:
- HB 42 and melaena
- FBC unremarkable otherwise.
- Upper GI investigations normal.
- Transfused to Hb 80. Currently stable.
- Anaemia screen – negative
- Colonoscopy – 2 years previously for positive family history. NAD. No repeated as inpatient.
- Gastroenterology review – working diagnosis of angiodysplasia from AS. For review and possible pill cam as outpatient. Recommended to proceed with surgery if Hb remains stable.
Discussion
- Reviewed over 1 year at perioperative clinic
- Pill Cam – medicare requirements state requires colonoscopy within 6 months. Will take time, surgery already postponed.
- Erythropoiesis-stimulating agents (ESA)
- Cochrane review supports short term uses perioperatively in anaemic patients not responding to Fe alone, in whom all other causes of anaemia have been excluded, and perioperative blood loss is expected to be 500ml or more.
- No increase in 30-day mortality or perioperative adverse events
- Preoperative ESA and Fe-therapy prior to non-cardiac surgery reduces need for transfusion, and when ESA given in higher doses, improves Hb perioperatively.
- No evidence for improvement in patient-centered outcomes such as LOS and mean number of RBC units transfused per person
- Concerns regarding increase in thrombotic events, therefore not recommended in patients with uncontrolled hypertension, recent coronary or cerebral ischaemic events, and disseminated malignancy. More evidence required in this area.
- ESA could cause confusion in measuring blood loss in this patient
- How to give ESA’s:
- 600units/kg S/c weekly at least 3 weeks preoperatively
- Need to replenish Fe-stores first, even if normal as adequate stores are required to produce erythroid progenitor cells
- Ongoing discussion in conjunction with haematology – define group of patients who will benefit perioperatively
Plan:
- Monitor Hb
- No need for pill cam preoperatively if no ongoing losses
- Postpone 6/52, surgical team in agreement
PIG Notes November 18th 2021
Declining cognition, ? nephrectomy
83yo male with a very large renal cancer for hand-assisted laparoscopic nephrectomy. Urologists had arranged a CPET to help the decision-making process.
Background:
- HTN
- Subcortical stroke 2017
- RCC – large mass, visible externally and with a contralateral adrenal mass (likely metastasis).
Issues
- CPET result
- AT 8ml/kg/min and peak VO2 11ml/kg/min = elevated perioperative risk
- Not always used in this context as with cancer requiring urgent surgical curative treatment it may not offer additional risk stratification. Minimal opportunity for cardiorespiratory optimisation.
- Cognitive function
- Surgeon noted that Patient coped well with wife present, but cognitive deficits were obvious when she was absent.
- CPET MDT discussion prompted shared-decision making appointment at clinic
- MMSE in clinic 12-13/30.
Discussion
- Cognitive screening in clinic
- Very concerning when a patient scores 12-13/30 on MMSE, but what about 19-20/30 (a common score). Trajectory of their cognitive decline is important, speak with GP and look for geriatrician reviews or other MMSE sources.
- This patient’s MMSE was performed in front of his family which was useful in demonstrating to them clearly how frail he is.
- Accelerating his cognitive decline postop was seen as the biggest risk for him with this surgery.
- Goals of care/prognosis
- What is the role of the contralateral met in his decision making?
- Surgery thought to be at best curative, at worst palliative (bleeding and pain from renal capsular and peritoneal stretch (regardless of malignant v. benign status).
- PET scans not always helpful in diagnosing malignant vs. benign renal lesions, due to physiologic uptake of FDG in the kidneys. Can be useful for diagnosing metastases.
- Adrenal lesions, benign and malignant, also have variable PET avidity due to background high metabolic activity.
Plan
- Family discussion ongoing but likely patient will decline surgery
Bilateral TKR?
67yo female booked for bilateral TKR but “not if BMI > 40”
Background:
- Severe OA in knees and feet
- Mobilises with walking stick
- HTN
- CFS 5
- BMI just under 40
Issues
- Appropriate to do bilateral TKR
- Patient wishes for bilateral procedure as she is the primary carer for her husband with melanoma and was distressed at prospect of delay to second TKR
- Frail older patient, recovery is likely to be slow, and her ability to support her husband (especially if she has a complication) may be severely impacted.
Discussion:
- Who is a good candidate for bilateral TKR?
- ASA 1-2
- Patients aged 50-60 or younger.
Plan:
- Discuss concerns with surgeon. Likely unilateral TKR.
AVF, severe comorbidities
39yo male for formation L RCF next week
Background:
- ESRD
- Diabetic nephropathy exacerbated by an AKI
- Currently dialysed through permacath. Some blockages (resolved) but nil infections.
- Secondary anaemia – EPO, Hb 109
- T1DM
- Smoker 10/d and cannabis ++
- Malnourished, dry weight 54kg
Issues
- Difficult phone consultation
- Patient extremely difficult to engage in conversation, became agitated with attempts to clarify information.
- Unable to ascertain functional capacity
- Poor diabetes control
- Multiple admissions to ICU with DKA
- Fasting sugars 10-15. HbA1c unknown
- Ultra-long acting/mixed insulin at midday. How to manage this perioperatively?
- Potential for optimisation?
- Undifferentiated HFrEF
- Sestamibi as part of transplant workup showed EF 30%, asymptomatic (as far as could be ascertained). New development.
- Awaiting TTE (although pt unaware of this), no current booking, should we pursue this?
Discussion
- HFrEF
- In absence of F2F review, preop TTE may be helpful and is a necessary step for him, it is unlikely to change management.
- Point-of-care TTEs from ICU unable to be located
- Could this be uraemic cardiomyopathy?
- Classically that would present as diastolic dysfunction with hypertrophy and fibrosis, although chronic severe hypertrophy may lead to cardiomyocyte death and systolic failure.
- Fibrosis may lead to dysrhythmias and sudden cardiac death.
- Thought due to pressure and volume overload (HTN and anaemia), fibroblastic growth factors, chronic inflammation, systemic oxidant stress, RAA activation, insulin resistance, abnormal mineral metabolism and endogenous cardiotonic steroids.
- Response to traditional therapies is limited.
- Endocrinologist says they have worked extremely hard to achieve the once daily ultra-long-acting insulin and no further optimisation possible.
- Profoundly depressed or cognitively impaired?
- Services available within renal or transplant spheres?
Plan
- W/H ultralong acting insulin DOS and use insulin infusion while in hospital. Resume normal insulin with normal diet.
- Attempt to obtain TTE but don’t delay surgery if not possible preop.
- Line up a procedural anaesthetist who will confidently do the procedure under regional anaesthesia only.
Severe DCM, endovasular recanalisation
89yo lady for lower leg angiogram and popliteal recanalisation for non-healing ulcers.
Background:
- IHD – recent NSTEMI, diagnosed after prompted to see GP by clinic doctor for SOB during phone consult. 3VD. For medical mx.
- PVD – Ulcer now mostly healed while awaiting surgical mx.
- CCF – recent admission with decompensation. TTE shows severe global dysfx due to DCM, EF 20-25%. Not thought solely due to IHD (but other contributors unknown)
- CKD – eGFR 35 (likely over-estimation given her low weight)
- Ex tolerance – vacuums, shops, 1 FOS ok
Discussion
- Proceed with lower limb angiography/plasty?
- Able to lie flat
- Nothing beyond local anaesthetic needed
- Risk of presenting for emergency procedure (e.g., partial lower limb amputations) if this low-physiologic stress, low risk procedure is avoided.
- Optimisable?
- For further discussions with cardiologist given severity of CCF and recent decompensation
Plan
- Discuss with cardiologist as above
- Proceed
Perioperative Talk 