29F with cerebral palsy for revision of baclofen pump

Background:

• Cerebral palsy
  • Non-verbal
  • Mobilises with electric wheelchair, requires a carer to operate
  • Severe spasticity and contractures involving all four limbs
  • Significant scoliosis and restrictive lung disease
  • Gastrostomy tube for feeding
  • Central sleep disordered breathing?
    • Abnormal breathing pattern – crescendo/decrescendo pattern
    • Assumed to have significant restrictive lung disease. No formal spirometry
    • Recent overnight oximetry showed SaO2 maintained >90%

Issues:

• >1 year of episodic flushing, diaphoresis, tachycardia, tachypnoea 
  • Autonomic dysfunction?
  • Variable severity and duration of symptoms
  • Baseline tachycardia 110bpm (previous HR 100 so may be chronic) 
• Differentials include: 
  • Central dysautonomia – potential syrinx development  given cerebral pathophysiology
  • Hyperthyroidism 
  • Phaeochromotcytoma
  • Baclofen withdrawal due to malfunctioning pump
  • Pain and Anxiety component?
  • Atropine – PO secretions, episodes don’t appear to correlate with dose
  • Subclinical seizure activity

Discussion:

Perioperative Optimisation

• Exclude hyperthyroidism and pheochromocytoma preoperatively
• Co-ordinating investigations while under GA 
  • MRI – can be performed safely with baclofen pump?
  • Discussed with rehabilitation physician  – all baclofen pumps are MRI compatible, however, the magnetic field and associated increased temperature can cause the pump to malfunction. See attached article

• Consider change atropine to glycopyrrolate

Plan:

• Pathology testing for TFT’s, plasma, and urine catecholamines
• Consider MRI under GA 
• Discuss with treating teams – can we perform any further investigations while under GA/inpatient

84 yo lady for gastroscopy and colonoscopy

Background

• CVA – presumed cardioembolic
• PAF – DOAC
• Fe deficiency anaemia – chronic
  • AV malformation in small bowel
  • Managed with iron infusions
• CKD – stage 1
• Intracerebral aneurysm – under surveillance
• IHD – stented

Issues

• Melaena and anaemia – DOAC for CVA. Hb drop from 112 to 53.
• Previous gas/colon showed healed antral ulcer. 
  • Complicated by hypotension. Treated IVF and vasopressors. 
  • Required ICU for fluid overload.
  • Patient doesn’t want to have procedure – worried about having further cardiac failure, stroke, and ICU admission.
  • Patient concerns reasonable, unclear cause of previous event

Discussion

Proceed to surgery?

• Reasonable to proceed to gastroscopy –
  • low risk for fluid overload. 
• Colonoscopy – indication unclear
• More fluid shifts involved.
• RFA indication for colonoscopy states haemorrhoids
  • Consider less invasive investigations? Eg. proctoscopy/flexible sigmoidoscopy

Plan

• Proceed with gastroscopy only at this stage – avoid bowel prep and significant fluid shifts
• Liaise with surgical team regarding colocoscopy

PIG Notes 25th May 2023

• Obesity and Reverse Total Shoulder Replacement
• Thoracotomy – patient declining op
• Caesarean section – JW
• Open AAA – Juxtarenal
• Complex lower limb vascular reconstructions
• Cholecystectomy – multimorbidity

70 y/o M with recurrent gallstone pancreatitis. Several other episodes this year, not requiring hospitalisation.

Background:

• OSA- occasional CPAP compliance
• NYHA- Class III for breathlessness. TTE – nil significant issues detected.
• BMI 40
• ESRF- haemodialysis 3 times a week 
  • 500ml fluid restriction (oliguric)
  • Secondary chronic anaemia, using an ESA + Fe
• R) nephrectomy 2022 – postoperative ICU admission for vasopressor support and hyperkalemia management
• 4WW, mobility scooter for longer distances. Reduced exercise tolerance since ICU admission.

Issues:

• Functional decline
• Multimorbidity

Discussion:

• Perioperative risks: NSQUIP: 6.4% serious, 0.8% risk of death, 26 % functional decline 
• Conservative management carries significant risks with recurrent episodes of gallstone pancreatitis
• Patient motivated for pre-habilitation 

Plan:

• Pre-habilitation 6 weeks
• Dietitian review ongoing (BMI ) through dialysis

56 y/o M  with critical left leg ischemia. Possible procedure would be a very long, very complex, multi-faceted reconstruction. Conservative management would eventually result in AKA which may be complicated by poor wound healing due to ongoing vascular compromise.

Background

• CLL- WCC 38
• Smoker – cigarettes currently 5/d (recently ceased marijuana)
• Exercise Tolerance- DASI 3.94 METs – Limited by acute limb pain 

Issues:

• Cardiovascular – Reduced exercise tolerance, ? prior non-transmural infarct in RCA territory on sestamibi (but nil reversible ischaemia). TTE pending.
• Ongoing smoking – multiple strategies discussed in clinic and NRT provided

Discussion:

• Optimisation opportunities preoperatively – smoking only
• Conservative management is a poor option 

Plan:

• Await TTE Report
• Smoking Cessation 
• Likely proceed to surgery given poor conservative mx option

77 y/o F with 5.5cm juxtarenal AAA- complex EVAR therefore preference for open procedure, and recent increase in size.

Patient’s sister died from AAA rupture leading to significant patient anxiety and exercise avoidance.

Background

• Dyslipidaemia
• Current Smoker- 75 year pack history. Reduced – currently 3/day. Normal spiro.
• CFS: 4

Issues

• Elevated risk CPET results – low AT (8.9ml/kg/min), acceptable peak VO2 (16.4). 

Discussion

• Absence of respiratory issues (beyond residual smoking) to deter from open procedure
• BP remained within target range for known AAA (<180 systolic) during CPET suggesting prehabilitative exercise will be feasible
• Patient engaged in planning prehabilitation. Previously active so understands the feel/goals of activity. 

Plan

• Pre-habilitation 4-6 weeks, no need to repeat CPET 

Proceed to open procedure

37 y/o F  for electives LSCS and tubal ligation

Background

• Previous LSCS with spinal 
• Current Pregnancy- gestational Hypertension (on Nifedipine) and elevated LFTS and proteinuria (concern for evolving HELP Syndrome) 

Issues

• Jehovah’s Witness
• Product discussion with patient and documented would accept: Cell salvage, FFP And cryoprecipitate

Discussion

• For re-discussion on day of procedure with patient (confidentially) 
• Patient wishes should be determined in absence of partner or church representative presence

Plan

• Planned procedure Wed 1/6 (Procedural anaesthetist at meeting and aware)

73y/o F for Left thoracotomy and biopsy for para-aortic left node (PET avid). Not EBUS amenable

Recent Admission with proximal myopathy (improved with steroids) and PET AVID lesion noted – ? paraneoplastic syndrome causing weakness.

Background

• ? Scleroderma/Dermatomyositis (Recent reviews by Rheumatology- still undergoing investigations)
• AF – apixaban
• HTN
• DASI METS < 4
• CFS 6
• COPD
  • FEV1 0.94 , FEV1 1.8, DLCO 39%
  • Exacerbation in Feb 23
  • 96% on RA, hyperinflation of chest on examination 

Issues

• Patient not keen for procedure due to concern about high risks
• NSQUIP – Risk of death >5%; 12% complications, Readmission 13%
• Severe COPD, likely not optimizable

Discussion

• ? natural history of disease once tissue diagnosis is obtained
• ? options for treatment of presumed cancer without tissue diagnosis
• ? risk of anaesthesia and procedure outweighs benefit
• Respecting patient autonomy 
• Options for less invasive surgery?

Plan

• To Discuss with Oncology team re ? option for empirical therapy due to the high risks, ? likely natural history without treatment
• Discuss with rheum/onc – ? myopathy due to dermatomyositis (not cancer), ? other non-cancerous diagnoses possible for the lymph node
• To discuss with surgical team – is a thoracotomy required for a tissue diagnosis or is there an alternative option

68 y/o F for Reverse total shoulder replacement

Background:

• BMI 60
• Diabetes :
  • HBAIC 7.8% (from 10.6)  -Improved control 
• CKD : eGFR 52
• HTN
• OSA- CPAP compliant
• Echo- moderate diastolic dysfunction
• Poor mobility – FASF, weekly physiotherapy and hydrotherapy
• DASI- Mets:3.63

Issues

• Exercise Tolerance reduced: SOB on arrival to clinic
• Poor diabetes control
• Opioid tolerant (30 BD oxycontin)
• High BMI

Discussion:

Proceed versus alternative therapy (Steroid injection/ Nerve blocks)

• Weight loss would assist pain and potentially avoid the need for surgery (note other shoulder becoming more problematic – ? due to FASF)
• Consideration of non-surgical management options for pain 
• Surgical team unaware of FASF use – ? will be able to use FASF after surgery, ? patient safe to mobilise without it

Plan

• Delay for 3 months
• Weight loss – Dietitian referral to free clinic 
• Contact GP re. iron replacement and GLP-1 antagonist (weight loss + DM optimisation)
• Exercise physiologist to optimise exercise tolerance and mobility – ? avoid need for FASF
• If surgery proceeds, would need ICU level 2 given risk of respiratory compromise with OSA and phrenic nerve block

PIG Notes 27th April 2023

• Congenital heart disease and endoscopy – update
• Recent ACS, Complex urologic issues
• POCD risk, cholecystectomy
• Value of OT versus risks
• Surgery after pericarditis