Ovarian mass, decompensated liver failure

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. 

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.

Gynae surgery, DAPT and anticoagulant

43yo lady for EUA, D&C, and Mirena. 

Background

  • Abnormal uterine bleeding – over last 4 years. Menorrhagia and irregular bleeding. Hb 142. Fe studies borderline. Normal endometrial Pipelle biopsy.
  • Radical vulvectomy 2020 – malignant undifferentiated neuroendocrine tumour. Margins included. For radiotherapy as per last Gynae-oncology MDT.
  • Asthma/COPD – Current smoker
  • Complex PTSD and chronic pain syndrome – known to Dr Chris Hayes
  • Increased BMI
  • Immobility – walks with 4WW or uses wheelchair due to above issues.

Issues

  • IHD – multiple myocardial infarctions, last in 2018. DAPT. No regular cardiology follow-up.
  • LV thrombus 2018 – anticoagulated with warfarin.
  • IDDM – previously very poor glycaemic control. Recent HbA1c 7.1%. regular endocrine review.
  • PVD – multiple lower limb surgeries. Prolonged admission in 2020 with femoral endarterectomy/fem-pop bypass, fasciotomies, and multiple angiographic procedures.
  • Gynae were unaware of DAPT and Warfarin

Discussion

Correct procedure for this patient?

  • AUB and urinary incontinence are main issues for patient. 
  • Doesn’t want a Mirena as has had one previously; menorrhagia was worse and Mirena expelled itself. 
  • Patient thought she was having an endometrial ablation
  • Discussed above issues with surgical team. They organised to review her again in clinic and revisit her surgical options.

Management of anticoagulation and DAPT

  • Haematology review during last admission documented ‘unidentified prothrombotic state.’
  • No outpatient Haematology review arranged on discharge, no pathology on system.
  • A firm plan should be in place for management of anticoagulation and antiplatelet therapy perioperatively. 
  • Discuss with the cardiologist next week at MDT 
  • Is her triple therapy appropriate anyway? Could she just be on a NOAC?

Plan: 

  • Postpone surgery for 4 weeks 
  • Discuss at cardiology MDT
  • Re-review with gynae team organised
  • Referred to haematologist for investigation and advise on anticoagulation/DAPT

Hypothyroidism v PPM

66-year-old lady for TKR – initial preop 2019

Background:

  • IHD – Normal stress echo 2020. No angina. 
  • AF
  • MVP
  • Asthma

Issues

  • Bradycardia – 45bpm. Fatigued, no syncope.
  • Discussed at cardiology meeting.
    • Referred to own cardiologist
    • Recommended PPM
  • Bilateral pitting peripheral oedema. Complaining of orthopnoea and PND. 
  • DASI – 3.97, limited by fatigue
  • Echo 2020. 
    • dilated cardiomyopathy
    • severely dilated LV and LA
    • MR with prolapse 
    • Severe AS
  • Returned to clinic this week for PPM insertion
  • Thyroid function checked: 
    • TSH = 8 hypothyroidism.
    • on thyroxine but not checked regularly
  • Echo repeated due to oedema, orthopnoea, and PND:
    • Normal Aortic Valve. No stenosis!

Discussion:

Does patient need PPM?

  • Likely that symptoms be attributed to hypothyroidism
  • Imperative that hypothyroidism is addressed first

Hypothyroidism

  • Medication compliance issue should be considered
  • Timescale for expected changes with treatment of hypothyroidism.
    • weeks for improvement of symptoms 
    • 3 months for biochemical changes
  • Important to look at clinical picture as well as biochemistry when making decisions regarding fitness for surgery 
  • Current clinic guidelines for TFT’s:
    • ‘Monitoring is usually performed serially by GP. Consider testing peri-operatively if not done within 12 months if stable disease or sooner if frequent medication changes required/new cardiac arrhythmias/or signs and symptoms of thyroid disease.’ www.perioptalk.org
  • If request TFT’s will only get TSH value and need to request T3/T4 separately if required or if TSH abnormal

Aortic Stenosis?

  • Need to revisit cardiac imaging – possibility of error with previous echo regarding documented AS
  • Discuss at Cardiology MDT – ideal place to consolidate this information and facilitate liaison with regular cardiologist

Plan

  • Postpone for 6 weeks
  • Cardiology MDT 
  • Review perioperative guidelines for Thyroid Function testing

Partial gastrectomy, severe resp dx

77-year-old man with gastric cancer. Previously discussed at PIG as a consult.

Background

  • COPD- severe obstructive disease. FEV1 – 0.95, FVC – 3.36
  • AF – DOAC

Issues

  • Presented with UGI bleed – Hb 48. No opportunity for NAC or optimisation
  • Referred to respiratory physician for investigation of lung masses. Thought to be non-cancerous.
  • Living at home with exertional dyspnoea
  • Patient and family keen to proceed with curative surgery

Post-operative progress

  • Admitted for procedure – lap assisted distal gastrectomy
  • ICU post-operative for 24 hours
  • Discharged to ward

72 hours post-op:

  • Acute dyspnoea, APO, and AKI. Readmitted to ICU
  • Treated for HAP; High-flow oxygen, fluid overloaded. 
  • Creatinine increasing, anuria, and delirium
  • CT showed no surgical complications, echo – nil significant
  • Difficult situation – no way forward. 
  • Evidence – When to start dialysis? Outcomes unchanged when started earlier vs later. Surgical patients do better but likely better baseline than medical patients.
  • MDT meeting – dialysis commenced over 5 days. Stabilised and went to ward. Declined again and now palliative.

Discussion:

  • Preoperatively predicted that this would be a likely outcome if had any postoperative complications involving major organs
  • Family well-informed preoperatively

Breast cancer and severe eating disorder

49yo female with a large breast cancer requiring mastectomy.

Background

  • Anorexia, known to a psychiatrist and a GP with a specific interest in eating disorders
  • Excellent exercise tolerance
  • Major depression, previous self-harm, and suicidal ideation

Issues

  • Anorexia
    • Recent 300kcal/d intake causing 4kg weight loss, BMI down to 16.5, associated with pedal oedema
    • Initial plan for preop admission to CMN under gastroenterology, with nearby psych support, for NG feeding to improve nutritional state.
    • Patient has declined this and has cooperated with increased intake at home (up to 1500kcal/d at present) with associated weight increase and improved exercise tolerance (runs for exercise)
    • Recent pathology normal
    • Patient requesting bilateral mastectomy and reconstruction to occur at same time as feels she will not cope psychologically with mastectomy.
    • Patient has expressed she does not want the surgeon to speak with psychiatrist

Discussion

  • Has this patient’s psych history and current status been fully elucidated?
    • Alarming that she has declined surgeon and psychiatrist multidisciplinary discussions.
    • Is the psychiatrist fully aware of the current issues and plan?
    • Surgeon should attempt to gain approval from patient to speak with psychiatrist. Explain this to the patient in terms of our standard practice for liaison with specialist in any chronic health condition.
    • Provide patient with a framework for the proposed conversation to allay concerns about privacy regarding mental health history. 
    • Advanced plan for deterioration is required and psychiatrist should be involved. 
    • GP to act as intermediary as a second-line plan.
  • Should this patient have a mastectomy or a bilateral mastectomy with immediate reconstruction
    • Appropriate to proceed to surgery if patient continues current trajectory.
    • Surgeon will consider bilateral mastectomy and reconstruction given significant mental health history
    • Surgeon has advised that mastectomy without recon is preferable from a wound-healing perspective. High risk for wound breakdown, implant loss, and implant infection (especially if non-adherent to nutrition plan postop)
    • Mastectomy can be extremely distressing, even to psychologically well women.
    • Implant loss and wound breakdown are also very distressing. 
    • Infection is relatively easily managed with removal of implant (temporarily or permanently) and IV Abx.
  • Perioperative concerns with anorexia
    • Multiple body systems affected (see review article)
    • Bulimic variant is more physically damaging and may be further complicated by cardio/myotoxicity from emetogenic medications.
    • Risk of cardiac dysrhythmias and fluid overload due to cardiac changes. 
    • Other concerns – pressure area/nerve injury risks, active warming of patient and fluids needed, abnormal gastric emptying (assume unfasted), abnormal responses to NDMRs, concurrent drug or ETOH abuse (including amphetamines for weight loss), concerns about plasma levels of certain drugs which have a high unbound fraction if albumin is low.
  • Where should surgery take place
    • Public hospital with on-site psychiatric support seems most appropriate in event of psychological deterioration postop.
    • Risk of malnutrition and surgical complications will persist for weeks or even months postop. 
  • Postoperative disposition
    • If baseline ECG normal, nil evidence of dysrhythmias intraoperatively, and normal electrolytes, normal ward-based care is appropriate afterwards. 
    • A plan should be in place for daily electrolyte monitoring and telemetry should derangement occur. 

Plan

  • Reasonable to proceed with reconstruction from a purely physiologic perspective, given current nutrition status.
  • Surgeon to attempt to gain consent from patient to speak with psychiatrist. 
  • Consider involving psychiatry liaison service while patient admitted, for mental health wellbeing monitoring.
  • If not already done – check CMP/B12/folate/TFTs
  • NSW Health provides guidance for patients who are admitted to hospital with a decompensation of their eating disorder: https://www.health.nsw.gov.au/mentalhealth/resources/Publications/inpatient-adult-eating-disorders.pdf

Open AAA, high risk

70-year-old man for open AAA.  6cm supra-renal aneurysm. Asymptomatic

Background

  • Carotid Disease – under surveillance. No CVA/TIA
  • Non-hodgkins lymphoma

Issues

  • IHD 
    • Recent angiogram in Private hospital – chronic occlusion of RCA with collaterals. Mild to moderate LAD disease. 
    • Works as a cleaner. DASI 7.6 MET’s
    • Non-specific infero-lateral ST depression (1mm) on baseline ECG
  • Peripheral vascular Disease – aorto-iliac stents. Not suitable for EVAR
  • Complex surgery
  • Current Smoker – 28 pack year history. Normal Spirometry
  • Chronic Renal Impairment – Stage 2a

CPET

  • Sub-maximal test – HRmax152 (80%pred). Limited by assessor due to ECG changes.
  • Up-sloping infero-lateral ST depression during exercise
  • 1mm ST depression during recovery
  • No chest pain/dyspnoea
  • Patient happy to continue exercising.
  • Peak VO2 = 1.5ml/kg/min
  • AT 10.3ml/kg/min
  • Nadir VE/VCO2 36.4
  • HRR = 11bpm

Sestamibi 

  • Requested due to sub-maximal CPET and ECG changes
  • Reversible ischaemic changes in mid basal-inferior wall 
  • Reduced ejection fraction (40%) post-stress

Urgent cardiology appointment via Rapid Access clinic

  • Angiogram obtained from Private hospital (As Above)
  • Sestamibi should be interpreted in the context of a chronically occluded RCA
  • No angina despite good exercise tolerance
  • Echocardiogram – normal LV systolic function and no regional wall motion abnormalities
  • Nil further interventions required. 

Discussion

Increased risk of cardiovascular and renal complications

  • RCRI 3 – 15% risk of MI, cardiac arrest, or death within 30 days of surgery
  • Vascular Quality Initiative index:
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  • Existing renal impairment, supra-renal clamp, and predicted, complex surgery – increased risk of post-operative renal failure requiring long-term dialysis

Plan

  • Discussed with surgeon and procedural anaesthetist – decision made to bring patient and family back to clinic for shared-decision making. 
  • Convey increased risks outlined above and allow for family discussion before proceeding.

Revision TKR, polymorbidity

70-year-old lady for revision TKR. Fall and periprosthetic distal femur fracture in 2020

Background:

  • R Arm Amputation in 2015 – Necrotising Fasciitis. Long, complex ICU admission
  • Recurrent falls – multifactorial aetiology; UL amputation, charcot foot, hypoglycaemia, and knee locking.
  • BMI 44
  • Chronic pain – Migraines, phantom limb pain, and CRPS, medical marijuana and PRN opioids.
  • Subclinical hypothyroidism
  • TIA 2019
  • Chronic iron deficiency anaemia – managed by GP, regular Fe infusions

Issues:

  • IHD
    • 2 previous AMI with minimal symptoms. 
    • Sestamibi in 2019 showed a small area of fixed perfusion defect in LAD territory. 
    • Ongoing stable angina. 
    • Lifelong DAPT
    • Clinically bilateral pitting oedema to mid-shins 
    • 2-pillow orthopnoea. 
    • Last echo 2020 normal biventricular function.
  • IDDM
    • HbA1c 7.9%. 
    • Severe bilateral peripheral neuropathy. 
    • Frequent hypoglycaemic episodes. 
    • Regular endocrinologist review. 
  • Wheelchair-bound – since femur fracture last year. 
    • NDIS care-package in place, requires assistance with all ADL’s. 
    • Physiotherapy included in package, engaging with physio recently.
    • Previously able to walk 50m on flat

Discussion:

Risk assessment

  • High risk patient and complex operation
  • RCRI = 4 
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  • NSQUIP – above average for all variables, 70% discharge to nursing home/rehab facility.
  • Risks conveyed to patient, wishes to proceed. States she would never want to be in a nursing home long-term.

Cardiac optimisation

  • Discussed at cardiology MDT – high-risk, on optimal therapy
  • Echocardiogram – IHD, orthopnoea and peripheral oedema. 
  • Symptoms could be attributed to BMI, deconditioning, and immobility.

Diabetes

  • Reasonable HbA1c, unlikely to improve
  • Hypoglycaemic episodes ongoing
  • Preoperative endocrine consult – HbA1c above cut-off value for major joint surgery
  • High-risk for perioperative joint infection

Medical Marijuana

  • Prescribed by GP. Patient declining cessation in hospital
  • Endocrinologist recommended cessation – falls and hallucinations
  • Pharmacy contacted and IPU form completed

Decreased Exercise Tolerance

  • Discussed with surgeon, requests that patient can mobilise preoperatively
  • Rehabilitation will be difficult with current level of immobility/deconditioning
  • Referred to Kaden centre for prehabilitation in conjunction with Dr Jen Mackney and patients own physiotherapist.

Plan

  • Postpone for 6 weeks pending prehab and endocrine review