Pregnant patient with pulmonary embolism

PIG Meeting: 25th February 2021

34yo patient for elective CS, complex chronic and acute health problems.

Background

  • Ehlers Danlos Syndrome
    • Hypermobility type
    • ‘Marfans features’ (but not Marfans) with lens dislocation, high arched palate, spontaneous L PTx and known small bullae on R.
    • Bowel and gastric stasis requiring caecostomy.
  • Central and obstructive OSA – adherent to CPAP
  • BMI 38
  • Uveitis HLAB27 +
  • Raynaud’s phenomenon
  • Pregnancy – G1P0, nil foetal complications.

Issues

  •  PE – clinical symptoms + V/Q mismatch. On therapeutic clexane since ~10/7
  • ? Risk of aortic root aneurysm
    • Somewhat unusual picture. Risk difficult to quantify
    • Minimal harm from TTE (n.b. normal aortic root on subsequent TTE).
  • Risk of local anaesthetic failure
    • Patient has previously had some failed peripheral nerve blocks but successful rescue blocks

Discussion

  • What is Ehlers Danlos Syndrome?
    • The most common group of disorders in the family of genetically determined heritable connective tissue disorders.
    • Ligament laxity, joint hypermobility, fragility of connective tissues, poor wound healing.
    • Multiple subtypes with cardiac, GIT, autonomic and chronic pain issues.
  • Anaesthetic technique
    • Morphine adverse drug reaction (rash).
    • Neuraxial ideal. Consider CSE as colorectal team on standby given previous bowel surgery.
    • TAP catheters useful to avoid opioid exacerbation of gut stasis postop + risks of resp depression with opioids. Some reports of ineffective or partially effective LAs however not contraindicated and may provide substantial benefit.
    • If GA required, lung protective ventilation to minimise risk of bullae rupture. 
    • Note that Ehlers Danlos patients also have increased risk of bleeding post-operatively
  • Postoperative location (? Delivery suite, ? K2)
    • High VTE risk postop however this risk continues for weeks so no specific observation needed.
    • OSA well optimised
    • Normal care on K2 reasonable
  • Anticoagulation management
    • Discussed ? Need for conversion to heparin given known PE, to minimise time off anticoagulation
    • Overall thought that 24h off clexane reasonable and the logistics in starting/stopping heparin make it of limited value for this short period of time.

Frail patient with fungating tumour, severe cardiac disease

PIG Meeting: 25th February 2021

79yo nursing home resident with an invasive, fungating BCC or SCC on his leg.

Background

  • Cardiac disease
    • PPM for AF/CHB
    • Admitted with CCF last year – found to have PHTN with TR and RV failure.
    • Improved, discharged to NH
  • T2DM diet controlled
  • RA
  • CKD
  • Low exercise tolerance 3.6METS on DASI

Issues

  • Profound SOB
    • Rpt TTE – relatively unchanged, mild improvement
  • Anaemia
    • Hb 117 -> 83, ? Cause. Nil obvious bleeding.
    • Likely contributing to his SOB

Discussion

  • Should he have surgery?
    • Overall life expectancy appears short
    • Surgeon, family and patient all keen to proceed
    • Essentially palliative surgery for pain/symptom relief
  • Opportunities for optimisation?
    • Cardiologist r/v suggests HF reasonably controlled
    • PRBC transfusion (likely as part of surgical admission due to logistic challenges with patients in NH)
  • Anaesthetic technique?
    • Skin grafting required so SAB likely ideal. Care with haemodynamic given pulmonary hypertension.

Pregnant patient with mitochondrial degenerative disorder

PIG Meeting: 25th February 2021

34yo lady booked for elective CS.

Background

  • Mitochondrial degenerative disorder POLG (DNA Polymerase gamma gene – responsible for the integrity of mitochondrial DNA)
    • OSA – Central and peripheral
    • Bulbar dysfunction
    • Ophthalmoplegia
    • Ataxia, pre-pregnancy 2km with FASF, now mostly in wheelchair. Falls
    • Epileptiform EEG
  • Obesity BMI 38
  • Pregnancy:
    • G1PO
    • Pregnancy itself uneventful.
    • Nil genetic testing of partner or foetus
    • On prophylactic clexane due to immobility
  • Distance patient (Tamworth)

Issues

  • Exercise tolerance reduction
    • TTE in December normal, but known risk of cardiac decompensation
    • Fatigue and SOB increasing. Progressive orthopnoea + possible PND. ? Pregnancy v. Pathologic process
    • Risk of cardiac dysrhythmias. Nil reported palpitations
    • Hasn’t seen cardiologist as part of antenatal care
    • Spirometry in clinic showed normal volumes
  • ? Seizures
    • Recent episodes of 50-60 desaturation events overnight. ? CPAP malfunction v. CCF v. seizures
    • Known epileptiform EEG.
    • Risks of rapid progression from partial seizures to refractory, fatal seizures with POLG
    • Lamotrigine being empirically up-titrated by neurologist
    • Ambulatory EEG cancelled by patient due to logistic challenges and lack of understanding about significance
    • Sodium valproate and MgSO4 contraindicated.
  • CPAP use
    • Machine alarming ? Cause
    • Patient now non-adherent

Discussion

  • Pre-op investigations
    • Baseline lactate (in anaesthetic bay) helps team to understand intra/postoperative levels
    • Baseline CK, CMP
  • Preop multidisciplinary reviews
    • Needs input from cardiology – speak with the cardiologist (Hatton) who works with high risk obstetric patients.
    • Needs CPAP review and optimisation
    • Needs ambulatory EEG
  • Post op care location
    • Given risks of refractory seizures, and need for repeated lactate monitoring and strict fluid balance, ICU level 2 necessary
    • Patient accepting of this.
    • Father of baby will be admitted to care for baby.
  • Anaesthetic technique
    • Neuraxial
      • Nil specific contraindications.
      • Spinous processes palpable and patient’s body habitus relatively conducive to positioning.
      • May require some head-up positioning. Negotiate with surgeons.
      • IT morphine(+/-) and TAP catheters to minimise postop systemic opioids to avoid gut stasis (known issue with POLG) and hypoventilation
      • Patient prefers SAB but happy to go with safest option
      • EDB (without spinal) for slow onset (avoid sudden resp accessory muscle paralysis) ideal.
      • Intrathecal catheter also an option
    • GA?
      • No MH risk
      • Non-depolarising MRs safe
      • Attention to vent/CO2 mx given seizure propensity
      • Difficult to detect seizures
    • Dedicated obstetric anaesthetist
    • IVF with dextrose while fasting

Total hip replacement with severe bilateral hip osteoarthritis

PIG Meeting: 18th February 2021

  • Elderly man seen in perioperative clinic for THR.
  • Requiring arthroplasty to both hips.

Background

  • Longstanding severe OA. Now wheelchair bound and sleeping in a chair
  • Significant bilateral peripheral oedema both legs, likely due to inability to mobilise/raise legs
  • Difficult social circumstances
  • Orthopaedic team consulted in perioperative clinic and discussed possibility of bilateral THR

Issues

  • Surgeon decided not suitable for bilateral hip arthroplasty. Likely due to frailty.
  • Discussion around optimal timing for the second joint replacement taking into VTE risk
  • No evidence but consensus was sensible to leave 6 weeks between surgeries
  • Update on case provided by procedural anaesthetist.
    • Unable to attempt neuraxial block due to difficulty in positioning
    • Significant post-operative delirium
    • Would have likely been a poor candidate for bilateral joint replacements
    • Predicted difficultly with rehab and post-operative mobilization due to severity of OA in other hip

Knee replacement with abnormal SESTAMIBI

PIG Meeting: 18th February 2021

73 year old man for unicompartmental knee replacement

Background

  • IHD with significant history of ACS requiring PCI between 2000 and 2008.
  • No symptoms reported in last 12 years.
  • NIDDM. HBA1c = 7.2
  • DASI 7 METS. Can mow lawn slowly.
  • BMI = 39

Issues

  • MIBI ordered in clinic – moderately impaired coronary perfusion reserve in a single coronary artery territory (RCA). Reduction in LVEF post-stress. Findings stratify the patient to be intermediate-high risk for perioperative coronary events during high risk surgical procedures
  • Dr Nick Collins reviewed and recommends deferment of procedure and coronary angiogram

Discussion

  • Suitability of testing given asymptomatic with reasonable functional capacity
  • AHA guidelines would suggest no requirement for non-invasive stress testing with DASI of 7 METS
  • Consensus that if patient had attended regular cardiology follow-up, he would have likely had a stress test in the preceding 12 years given diabetic patient with known coronary artery disease.

Plan

  • Defer surgery pending coronary angiogram +/- PCI

Laparoscopic cholecystectomy with severe COPD

PIG Meeting: 18th February 2021

67 year old lady for elective laparoscopic Cholecystectomy

Background

  • Recent admission for obstructive cholangitis

Issues

  • Moderate-severe COPD.
  • Current smoker
  • Recent deterioration in exercise tolerate to 20-30m. NYHA class 3 dyspnoea.
  • Spirometry significantly deteriorated from previous. FEV1 = 0.63 (30% pred), FVC 0.94.
  • No active infection
  • On Clozapine under psychiatry care for schizophrenia

Discussion

  • Are there any alternatives to surgery? ERCP and sphincterotomy or stent?
  • Requires further discussion with surgical team, laparoscopic cholecystectomy is usual pathway for these patients 
  • Requires respiratory assessment and optimization. Potential benefits of perioperative steroid therapy
  • Cardiac assessment given on clozapine? Has echocardiogram booked to review any possible cardiac complication of clozapine therapy
  • Suggestion of potential benefits of preoperative hospital admission for respiratory optimization
  • Smoking cessation discussed

Plan

  • Defer for 4 weeks while awaiting respiratory review and echocardiogram
  • Further discussion with surgical team regarding respiratory co-morbidities and surgical options
  • Liaise with psychiatry team given current clozapine therapy

Bronchoalveolar lavage for pulmonary alveolar proteinosis using VV ECMO

PIG Meeting: 18th February 2021

Update on patient presented at CME – severe type 2 respiratory failure during GA with DLT for broncho-alveolar lavage (BAL).

24 year old male with pulmonary alveolar proteinosis

Background

  • Previous medulloblastoma treated with radiotherapy and chemotherapy
  • Complicated by deafness and renal failure
  • Renal transplant
  • Restrictive lung physiology

Procedure completed with femoral access and jugular return veno-venous ECMO.  Required 5L BAL for each lung with washing out of alveolar protein. 24 hours V-V ECMO support and successfully extubated.

Ivor-Lewis Oesophagectomy with Ischaemic Heart Disease

PIG Meeting: 18th February 2021

69 year old man with Oesophageal cancer

Background

  • Routine preoperative CPET testing revealed ischaemic ECG changes, suspicious of LM disease

Issues

  • Asymptomatic. Noted to have an excellent exercise tolerance on DASI.
  • Exercised to 90% of predicted HR with AT of 15.6ml/kg/min and VE/VCO2 24.6. This represents excellent exercise capacity and would usually indicate patient is fit to proceed to major surgery.
  • Discussed with Dr Collins at the Perioperative Cardiology meeting. Concern re left main coronary artery disease – recommended angiogram
  • Coronary angiogram which revealed mid-eccentric LAD stenosis of 60-70% with normal LVEF
  • No coronary intervention required. Plan to proceed with surgery

Discussion

  • Value of CPET in this instance. Was it a useful test?
  • Discussion centered around the finding of a pathology that didn’t require any intervention.
  • Patient didn’t perform Prehab due to possibility of coronary disease. Was he disadvantaged?
  • Should we be performing CPET in all patients for major surgery or just in those who are clinically borderline candidates?
  • Consensus that there is sufficient evidence for CPET testing perioperatively for major surgery. This patient performed well despite recent completion of NAC and that provides treating team with good prognostic information perioperatively.
  • No delays to surgery and prehabilitation unlikely to improve fitness further as already excellent.

Plan