Elderly, frail gentleman for gastroscopy and Colonoscopy – background of PR bleeding with supratherapeutic INR. Nil episodes since INR within appropriate range.

Background: 

• CVS: 
  • OOHCA 2018 with 4x stents 
  • Metallic MVR 2004
  • Severe TR
  • AF 
• Severe eczema + Grover’s disease (itchy rash) – recent course of prednisone 
• Resp: OSA with CPAP 

Issues

• CVS – Recent functional deterioration, low exercise tolerance ++  
• Anaemia – persistent. Iron replete

Discussion

• Perioperative Risk
  • High anaesthetic risk due to CVS morbidity
  • Physiologic stress of bowel prep and requirement for interruption of anticoagulation
• Goals of care
  • Low likelihood of positive finding as per proceduralist (probable small bowel angiodysplasia, nil lesions on CT colonography and previous normal gastroscopy)
• Potential for gastroscopy (without biopsies) without interruption to anticoagulation? 
• If further bleed with appropriate INR, would we consider greater need for scope? 
• ? patient optimized – recent deterioration ++ in exercise tolerance. Nil obvious signs of heart failure on examination. 
• Clinicians with longer term care of this patient may be better positioned to determine how procedure aligns with goals of care

Plan

Discuss with cardiology re optimisation and bridging requirements (if requiring biopsies)

PIG Notes May 18th 2023

• Pleural effusion and renal failure
• TSR and chronic pain
• Unexplained weight loss, cervical laminectomy
• Obesity, deconditioning, nephrectomy
• Cranial nerve palsies

R ocular surgery – transfer of eye muscles and eye botox for CN palsy 

Background: 

• Medullary Cavernoma
  • Recurrent Intracranial haemorrhage 
  • Multiple ICU admissions 
• Lone living – independent ADL’s 
  • Home supports 
• DASI 5 MET’s 

Issues: 

• LMN Facial Nerve palsy – forehead involvement
  • PEG in situ – can now tolerate a normal diet with no choking, or aspiration 
• Hoarse voice with pronounced dysphonia o Aetiology uncertain – trauma from ICU stay/repeated intubation 
  • Manifestation of cranial bleed? 
  • Previous grade 1 intubation – no record of trauma/difficulty 
  • No red flag symptoms – no dyspnoea, can lie flat, 
  • Vocal changes have been consistent since hospital admission. No deterioration 
  • Nasendoscopy – unilateral VC paralysis 
• Complex central sleep apnoea – uses CPAP 

Discussion: 

• Airway plan – ETT vs LMA
  • Unlikely to be suitable to for LMA 
  • Often lengthy 
  • May require muscle relaxation to facilitate muscle transfer 
• Surgical complexity – unknown.
  • Booked as day procedure 
  • Need to liaise with surgical team 

Plan:

• Discuss with surgeon 
• Post-op disposition:ICU 

58 yo F with renal mass → renal clear cell carcinoma and increasing in size 

Background 

1. Goitre → T3/4 normal and TSH suppressed. 
2. OSA – CPAP
3. AF o SVT/rAF post induction previously 
4. HFpEF 

Issues: 

• Physical deconditioning
  • BMI 46 
  • Mobilises with wheelchair 
• Current smoker 
• Complicated perioperative course – Breast WLE 2023. Poor wound healing post excision and infection. Required re-intubation and ICU post-operatively 
• Multiple visits to perioperative clinic – decision not to proceed to surgery made by 2 senior anaesthetists based on significant co-morbidities.
  • Recent Cystoscopy and RPG/lithotripsy for renal calculus – uneventful surgery
  • Request for surgery re-submitted 

Discussion 

Perioperative Optimisation 

• Minimal changes so far with lifestyle modification – obesity, smoking 
• Recommendation not to proceed is not preclusive 
• Patient has been extensively counselled on perioperative risk and wishes to proceed. 
• Issue now is optimisation and prevention of post-operative complications – biggest risk PPC 
• Risk factors should be re-addressed with the new incentive of a surgery date
  • Weight loss – consider addition of GLP-1 analogue 
  • Smoking cessation – coaching previously offered, consider Champix? 
  • Prehabiliation 

Plan: 

• Metabolic clinic referral 
• Prehabilitation 
• Post op disposition: CPAP, HDU – do not start without HDU bed confirmed given previous extubation failure. 

84yo lady for cervical laminectomy. 

Background 

• Spinal canal stenosis – severe, numbness and weakness all 4 limbs, gait and balance affected, incontinence issues. 
• IHD – NSTEMI 2019, medically mx 
• HOCM – apical hypertrophy, nil LVOT, EF 65% 
• Dyslipidaemia 
• 4WW, assistance with ADLs 
• DASI 3.3 METS 

Issues: 

• Unexplained weight loss
  • 20% over 8 months 
  • Anorexia, decreased intake 
  • Concerning for occult malignancy 
• Surgeons + gastro consulted -> recommended CT/PET scan, endoscopies if anaemic 

Discussion: 

Should surgery proceed? 

• Non-elective procedure given imaging and clinical e/o myelopathy 
• Surgeon notes specify that improvement unlikely. Goal is to prevent further decline. 
• Timing of surgery relative to investigations? 
• Where possible, Ix should all be undertaken prior to surgery, as a palliative diagnosis may be made which would likely negate surgery 
• BMJ Best Practice guidelines have a summary regarding the patient with unintentional weight loss – See attached article 

Plan: 

• Add on TSH, HbA1c 
• Await imaging 
• Postpone surgical date 
• Liaise with surgeons regarding the above 
• Liaise with gastro team if anaemia identified – availability for urgent endoscopies 

86 yo M for shoulder replacement 

Background: 

• PPM – Symptomatic bradycardia 
• CKD stage 3. 
• Valvular disease, pulmonary hypertension 
• BMI 30 

Issues: 

• Chronic pain neck and shoulder pain – managed with pregabalin and oxycodone
  • Unable to tolerate NSAID’s due to renal impairment 
• Recent hospital admission
  • Deconditioned +++ 
  • Anaemia Hb 106, Ferritin high, Normal B12/folate, CRP pending, FOBT pending 
  • Delirium – attributed to urosepsis 
• Shoulder and arm pain exacerbation
  • Background of degenerative cervical spine and radiculopathy 
  • Shoulder pain worsening 
  • Steroid injection with little effect 
  • TSR being considered; Surgeons anticipating difficult and long procedure 

Discussion: 

Options for Pain Management 

• Non-operative treatment: no improvement with intra-articular steroid injections
  • Interventional pain options include repeat steroid injection, targeting suprascapular nerve 
• Pain may not be relieved by shoulder replacement
  • High-risk of perioperative complications, particularly delirium and cognitive decline 
• Anaemia investigations – possible slow recovery from recent illness
  • Differentials include Age related BM failure and occult loss 
  • Discuss with haematologist after checking CRP and Fe studies post urosepsis event tp exclude acute phase rise in ferritin 
  • Consider gastroenterologist opinion if no improvement 

Plan: 

• Delay operation 
• Consider non-operative treatment eg target suprascapular nerve 

76 yo lady for VATS pleurodesis – drainage pleural effusion 

Background 

• IDDM
  • IHD – CABG 2016, stents x2 since, o Angio 2020 all are occluded except 1 
  • PPM – 3rd degree HB o AF underlying rhythm 
  • Moderate MR 
  • Pulmonary hypertension 

Issues 

Large symptomatic pleural effusion – aetiology unknown

• Large symptomatic pleural effusion
  • Transudate 
  • Malignancy vs cardiac vs renal overload 
  • Recent Weight loss 
  • Failed conservative treatment – had pigtail catheter inserted and fluid drained. Talc down drain before removal. Immediate reaccumulation 
  • pro BNP > 45 000 
• ESRD – dialysis dependent o Anuric 
  • Fluid removal limited by limited by hypotension 
  • Hyperkalemia 

Discussion 

Proceed to surgery? 

• High risk patient – NSQUIP mortality 20% 
• Non-operative management has failed 

Opportunity for optimisation? 

• Renal team – any options for dialysis. Renal palliative care team involvement 
• cardiologist review and advice

Treating symptoms v. investigation of underlying cause

• Should she have malignancy workup?

Plan 

• Cardiologist referral –discuss with Dr Collins next week 
• Discuss with surgical team and renal team regarding requirement for further investigations/optimisation 
• Suggest referral to renal palliative care 

PIG Notes February 17th 2022

• Deconditioned, large hernia
• AKA after BAV
• Middle cerebral artery bypass
• EVAR and ? carcinoid
• MND and minor surgery

60yr old male with a large tender SCC on his chest.

Background:

• Motor neurone disease
  • Diagnosed 2011
  • Bed bound, wheelchair dependent
  • Bulbar palsy, cannot lie flat (will aspirate), requires suctioning even in semi-recumbent position
  • Full PEG feeds
  • Continuous BiPAP
  • Reasonable QoL, enjoys spending time with his supportive family
• Ex smoker
• IHD – AMI 2015, managed medically
• HTN

Issues

• Should surgery proceed
  • While this gentleman has limited life expectancy the lesion is painful and growing (currently ? 5x5cm)
  • Surgeon confident the procedure can occur under LA, including the graft donor site.
  • With both patient and surgeon very motivated to do the procedure under LA and to work under challenging conditions, high likelihood of success. 

• Advanced care planning
  • Complex discussion. Not previously documented or formalised by patient.
  • The patient would ‘like one shot at dying’ meaning if he is in a situation where he has substantially deteriorated he does not want active resuscitation.
  • However, he may consider brief periods of additional support (e.g. intubation) if he had deteriorated but not to the extent of, for example, losing consciousness, and if he had a chance to return to his current level of function and disability.
  • This is very fine distinction and requires ongoing thought from the patient between now and surgery, and further discussions between the anaesthetist and patient on the day of surgery.

• Level of postoperative care
  • Ideally this man will have his procedure under LA and return home to his well-supported home environment. No ICU bookings made.

Discussion

Motor neurone disease

• AKA amyotrophic lateral sclerosis
• Progressive dx characterized by degeneration of motor neurons within cortical, brainstem and ventral cord locations.
• Combination of upper and lower motor neurons involved.
• Focus of care is palliative and symptom control, including respiratory and nutritional support.
• Riluzole is an anti-glutamate medication used for symptom control

Perioperative pharmaceutical implications of MND

• Baclofen, diazepam and dantrolene may be used for spasticity
• Abrupt cessation of baclofen may cause an MH-like crisis.
• Avoid depolarising neuromuscular blockers
• Use heavily reduced non-depolarising neuromuscular blocker doses (and a PNS to guide use).
• Consider higher doses of rocuronium and sugammadex for PNS-guided full reversal.
• No association with MH, volatile anaesthesia safe to use.

Plan:

• Proceed to OT under LA
• Clinic anaesthetist to discuss with procedural anaesthetist once OT date and allocations known
• Aim to d/c home same day
• Further clarification of advanced care plan between procedural anaesthetist and patient

84yo male with 5cm AAA for EVAR

Background

• Nil CVS/RS dx
• Essential tremor
• MOCA 24/30
• Fungal sinusitis

Issues

? Carcinoid

• Recent hospitalization with severe pruritic rash, postural dizziness, flushing. Suggestion of carcinoid syndrome but no testing undertaken.
• Vascular surgeons happy to defer surgery given AAA 5cm, nil overly concerning imaging findings and asymptomatic
• Panel of biomarkers arranged
  • Serotonin, glucagon, VIP, urinary 5HIA, chromogranin A
  • Chromogranin A elevated (320) however PPIs and H2 antagonists can lead to elevations
  • Endocrinologists queried mastocytosis, however tryptase level was normal
• Endocrinologists said that the flush did not sound like a carcinoid flush and were confident that this did NOT represent carcinoid syndrome
• Rash biopsied (non-specific), commenced on an IL inhibitor for the rash. This medication (like many new monoclonal therapies) does not have an associated infection risk and does not need to be withheld perioperatively.

Plan

• Proceed with the EVAR