PIG Notes 8th June 2023

• Refusal of blood products, VBAC
• Whipple’s Procedure
• Unexplained cardiac arrest under GA
• Pinnectomy, multiple teams involved
• ? capacity after TBI
• Myotonic dystrophy and large volume botox

37yo hysterectomy + hernia repair  multidisciplinary surgery involving gynae/gen surg

Background: 

• Fibroid uterus, significant adhesions, previous failed surgery (unable to access the uterus)
• Myotonic dystrophy
  • Reflux ++, slurred speech and dysphagia
  • Normal TTE and PFTs
• Smoker

Issues:

• Large Botox dose in context of myotonic dystrophy
  • Neurologist concerned with dose and potential for systemic absorption and prolonged exacerbation of muscular issues
  • Surgeon feels the high dose botox is essential to success of the procedure

Discussion:

• Botox use in this setting
  • Injected into abdominal musculature
  • Takes 2-3 weeks for full response
  • Nil evidence/ literature around high dose botox dose in muscular dystrophy
  • Systemic absorption – risk of headaches, fever, HTN, generalized weakness, dysphagia, subsequent aspiration)

Plan:

• Await further MDT planning between neurology and surgeons
• ? reduced botox dose may be possible

45yo L with previous aneurysm and decompressive craniotomy  for titanium cranioplasty which may be anticipated to provide some additional neurologic recovery.

Background: 

• CVA
  • Long rehabilitation admission
  • Residual language, hemiparesis and cognitive impairment

Issues:

• ? patient capacity
  • Pt refusing to proceed with surgery/ treatment despite high risk of further head injury with no bone flap and expected gains with cranioplasty
  • Often refuses treatment and observations in clinic or ED settings

Discussion:

• Assessing decision making capacity
  • Neuro-psych referral for guardianship
  • Emergency guardianship and treatment authority can be provided in more time-critical situations (may be required in this setting) 

• How to physically proceed with perioperative care even if guardianship in place?
  • Physical challenges beyond those of a non-cooperative child
  • Restraining adults not ideal or common in this setting
  • Having the guardianship in place may be sufficient to placate the patient
  • For further consideration

Plan:

• Await further conversation with neuro-psych

63yo SCC ear for pinnectomy

Background

• Severe COPD
  • Frequent exacerbations
  • Still smoking
  • Regular steroids for 2yrs, unable to wean
  • Recent commencement of azithromycin, significant improvement
• Lives alone, functional

Issues:

• Multiple teams involved but lack of ownership – ENT, radonc, plastics
  • Patient receiving misinformation (or lack of information) regarding surgical plan, likely cosmetic outcome, effects on hearing.
  • Verdict reached that patient was palliative and only suitable for radiotherapy, although not clear how this decision was made.

Discussion

• Challenging when multiple teams involved but no MDT in place
• Perioperative clinicians/service often ideally placed to coordinate the patient’s perioperative journey

Plan:

• Patient requires repeat surgical consultation to fully understand the procedure and provide informed consent.
• Pt seems appropriate for both radiotherapy and surgical procedures

50s male, elective craniotomy and clipping cerebral aneurysm.

Background

• Cardiac arrest on induction
  • PEA (nil further info provided)
  • Resolved with adrenaline, episode of VT post adrenaline
  • Experienced neuro anaesthetist
  • Patient anxious ++ since (on background 

Issues:

• ? Cause
• Tryptases normal
• Allergy IDT all normal to all agents
• Cardiac: Normal Troponin, TTE, stress TTE, small QT prolongation, Holter pending

Discussion:

• ? unrecognized drug error

Plan:

• Present at cardiology meeting to exclude 
• Could check TFTs – update – normal
• Nil suggestions with change in management for subsequent anaesthetic
• Notify procedural anaesthetist

64yo pancreatic ca. Diagnosed 12/12 ago. Questionable resectability due to proximity to hepatic artery, so had chemotherapy, followed by radiotherapy to improve surgical prospects. Remains uncertain.

Background:

• Quit smoking 12months ago
• Dyslipidaemia
• Pancreatic cancer
• Asthma/ COPD – nil exacerbations this year. Exacerbation last year requiring steroids.

Issues:

• Perioperative risks:
  • CPET – results in low risk stratum although some respiratory limitation
  • Frailty score 2 
  • NSQUIP suggesting low risk of death, 30% risk of serious complication

• Lack of advanced care planning

• Optimisation opportunities?
  • Prehabilitation specialist arranging local exercise program

Discussion:

• Advanced care planning discussions must always be offered but must be tailored to individual patients and their preferences around discussing these issues. 

Plan:

• patient has been referred for advanced care directive 
• proceed, nil further optimisation required

Potential LSCS (patient trying for VBAC).

Background 

• Previous Emergency LSCS for failure to progress
• Anaemia

Issues

• Declining blood products
  • Concern over receiving blood from someone who has had COVID Vaccine. 
  • Will only accept if ‘going to die’ or would like re-discussion if blood transfusion indicated a less emergent setting
  • Patient asking for cell salvage currently low stock of disposable products

Discussion

• Ensure all sources of anaemia have been optimized prior to OT (B12/folate/Fe)
• Important to establish exact beliefs behind product refusal and individual products
• Cell saver only gives RBCs, but not clotting factors/ fibrinogen which are important in all massive transfusion settings
• Intra-operative blood transfusion in obstetrics is only really used when there is a real threat of significant morbidity or mortality
• Patient low risk of PPH
• Cell salvage may be a distraction in this setting, where early clotting factor replacement would likely be essential and the patient would accept blood products in a life threatening situation
• Cell salvage in pregnancy
  • Potential risk of amniotic fluid embolism and rhesus isoimmunization (no serious adverse events yet reported)
  • RANZCOG recommends cell salvage when >1000ml blood loss is expected, unclear benefit if <1000ml blood loss. 
  • Contraindications
    • Contaminants such as faeces, haemostatic agents (e.g. gelfoam)
    • History of HITS (ACD anticoagulant may be used instead of heparin)
    • Homozygous Sick cell disease 

• Benefits No risk of allogenic transfusion reactions/ blood born infectionsCan be useful when antibodies present/ crossmatching problematicSafely administered along with uterotonics and TXASalvaged RBCs more physiologic than stored blood (temp, 2,3DPG, pH and K)

• DisadvantagesRed cells only returned, nil clotting factorsCost of device and disposable, training costsDedicated staff member used (and must be available)Setup time may limit utility during an E0 caesareanAvailability of resources

• https://resources.wfsahq.org/atotw/intraoperative-cell-salvage-in-obstetrics/#:~:text=Cell%20salvage%20is%20a%20safe,risk%20factors%20for%20postpartum%20haemorrhage.
• https://bmcpregnancychildbirth.biomedcentral.com/articles/10.1186/s12884-020-03138-w

Plan

• Discuss with patient and document thoroughly, treat patient as normal as we only give RBCs if absolutely necessary anyway
• Not for cell salvage

PIG Notes 1st June 2023

• Endoscopies, multimorbidity, advanced age
• Dysautonomia, uncertain aetiology
• Vocal cord palsy for injection
• Unstable C-spine for fixation

70F severe rheumatoid arthritis with unstable C-spine deformity requiring fixation from cervical to thoracic spine

Background

• RA
  • Weekly MTX + prednisone 7.5mg OD
• Distance patient 
• Unsupported at home, IADLs

Issues:

• Lower neck instability – Progressive
• Previous C-spine fixation – uneventful AFOI
  • Post-op infected hardware requiring removal/replacement
  •  McGrath+ bougie – no airway issues documented
  • ICU admission post-operatively
• Severe respiratory disease – bronchiectasis and severe pHTN
  • Puffers, saline nebs – productive of 100ml sputum everyday post saline nebuliser
  • Weekly percussion Physiotherapy – patient feels very beneficial for sputum clearance
  • Stable disease, home O2 not indicated

Discussion

Perioperative optimisation

• Cardiology and respiratory review in last 6/12 – nil optimisation required
• Prehabiliation – benefits of perioperative physiotherapy and secretion management?
  • postural drainage has minimal evidence base, percussion has better evidence if high sputum load, oscillatory PEP is most useful. Increasing use, in CF population

Conduct of anaesthesia

• AFOI vs asleep FOI – uneventful intubation post insertion of original hardware
• However, has had further hardware since and now an unstable neck
• Patient not assessed clinically – difficult to ascertain what is required until face-to-face review

Plan:

• Proceed to surgery
• Prehab coordinator has organized extra perioperative physiotherapy sessions close to patients home
• Patient will attend outpatient PT here for 2 days leading up to admission

84F for microlaryngoscopy and VC injection for unilateral vocal cord palsy

Background:

• Bowel Adenocarcinoma – recent diagnosis, awaiting surgical review
• Vocal cord palsy – Idiopathic
  • frequent botox injections
  • Nasendoscopy – nil else significant

Discussion:

Proceed to Surgery?

• Vocal cord usually moves over time, leading to resolution of vocal changes
• Indication is prevention of aspiration
• Surgery may not be required if symptoms improved
• Nil recent aspiration events
• Possibility of further surgical procedures for bowel adenocarcinoma – risk of ongoing aspirations?
• ENT discussion – happy to cancel, states likely no complications from not proceeding.
• Informed consent process – patient happy not to proceed at this time

Plan:

• Procedure was cancelled