Dental extractions in preparation for cardiac surgery

PIG Meeting: 1st July 2021

67-year-old man for 2 dental extractions in preparation for AVR

Background:

  • Asthma – daily Ventolin for dyspnoea but no admissions or steroids
  • OSA – compliant with CPAP
  • TIA – 2019
  • Chronic kidney disease – stage 3
  • Chronic cellulitis and lymphoedema – on long term antibiotics

Issues:

  • Severe AR – awaiting AVR.
  • HFrEF – 39%
  • AF – Apixaban and Sotalol
  • Pulmonary hypertension – recent right heart catheter; PAP = 57mmHg
  • NYHA class 3 Dyspnoea

Discussion:

Anaesthetic techniques

  • High risk patient for low-risk procedure
  • Dental extractions under local anaesthesia would be lowest risk
  • General anaesthesia would carry significant risk of cardiovascular morbidity and require arterial line/prolonged recovery stay

Anticoagulation

  • Maxillo-facial surgeons happy to perform 1-2 dental extractions on anticoagulation

Plan:

  • Local anaesthetic approach with continuation of anticoagulation
  • Discuss with procedural anaesthetist and surgeon

Blood product consent

PIG Meeting: 1st July 2021

49-year-old lady for Laparotomy and Hysterectomy for fibroid uterus and menorrhagia      

Background:

  • Very large multi-fibroid uterus
  • Menorrhagia – Fe deficiency anaemia in past requiring Iron infusion
  • Fit and healthy lady
  • Active, normal BMI

Issues

  • Jehovah’s witness, Provided advanced care directive regarding acceptable blood products
  • Inconsistency between products listed on ACD and those available for use in Australia, for example, haemoglobin

Discussion

Consent for Blood Products

  • Frequently find ACD from Jehovah’s witness patients that list products not available in Australia
  • Helpful strategy is to direct patients to the Red Cross website, explain available blood products and ask them to discuss with relevant advisors as to which they are happy to accept
  • Essential that patients are adequately informed and consented preoperatively
  • Jehovah’s witness website has many resources, may be helpful for anaesthetists to review information that patients are provided by church
  • Majority of people agreed that they document patient’s wishes with regards to blood products in the event of a life-threatening emergency.
  • This is best done at the perioperative consult as patient may need time to consult with family and church

Clinical Strategies to avoid Blood transfusion in this case

Preoperatively:

  • Optimising Haematinics, anaemia screen and replacement as appropriate
  • Consider use of tranexamic acid or Mirena in menorrhagia
  • Fibroids – embolization, Zoladex – reduces size, takes 6 months to work and undesirable side effects.
  • Nutrition advice and weight loss if appropriate

Intraoperatively:

  • Liaise with surgical team regarding expected blood loss/difficult of surgery
  • Consider use of cell salvage
  • Intraoperative tranexamic acid to be considered

Plan:

  • All above strategies employed
  • Liaise with surgeon and procedural anaesthetist
  • Consider update of clinic guideline/proforma – ongoing

Acute psychosis and hernia repair

PIG Meeting: 1st July 2021

37-year-old lady for elective repair of an epigastric hernia

Background

  • Significant mental health history with multiple inpatient admissions – voluntary and involuntary
  • Polysubstance abuse
  • Multiple previous hernia repairs

Issues

  • On day of surgery, patient thought she was being admitted for a caesarean section
  • Support person confirmed this, and alleged patient had been using amphetamines recently
  • Procedural anaesthetist reviewed patient who reiterated she was pregnant, and it was her due date.
  • Patient thought that the investigations for the hernia were for obstetric purposes
  • Beta-HCG negative
  • Postponed in conjunction with surgical team
  • Psych liaison contacted and recommended admission, but patient absconded post review
  • Outpatient welfare visit and psychiatry follow-up organised by Psych-Liaison nurse

Discussion

Could the acute Psychiatric deterioration have been identified preoperatively?

  • Unlikely, may have been very acute. Alleged recent excessive amphetamine use.
  • Difficult via phone consult

Management of Patient

  • Appropriate care provided to patient
  • Unable to consent at time of elective procedure
  • Psych Liaison services available at JHH and very helpful with this case

‘Not seen’ warning note

PIG Meeting: 1st July 2021

60-year-old lady for elective lumbar foraminotomy

Background

  • NIDDM – HbA1C = 7%
  • OSA – on CPAP
  • Hypertension
  • Current smoker
  • Radiculopathy – bilateral foraminotomies at a lower level 6 months ago without issue

Issues

  • Timing of booking/covid backlog/increased workload at periop clinic – no time to perform a perioperative consult
  • Not seen warning note generated
  • Cancelled on DOS as on SGLT2 inhibitor, not discontinued

Discussion

Could this cancellation have been avoided?

  • Multiple factors contributing to failure to cease SGLT-2 inhibitor.
    • Patient had same surgery recently and it was ceased at that time
    • Discharge medications and recent perioperative instructions highlighted she was taking this medication
    • SLGT-2 not flagged on the RFA
  • Patient may not remember medication instructions
  • Surgical registrars often fill the RFA and may not be aware of the perioperative requirements for SGLT-2 inhibitors.
  • Additionally, perioperative nurses are triaging many cases per day, they rely on the GP referral/RFA and often don’t have enough time to read through the previous clinic notes

Would it have been appropriate to proceed?

  • Ultimately it is the decision of the procedural anaesthetist
  • According to most recent ANCZA/ADS statement, it may be appropriate to perform day surgery on patients who have continued SGLT-2 inhibitors under certain conditions. (See table below)
  • This surgery may be complex due to previous surgeries
  • Patient has good glycaemic control but significant co-morbidities.
  • Elective procedure, consensus that best to postpone

TKR with incomplete revascularization

PIG Meeting: 24th June 2021

69yo male patient in private hospital for TKR

Background:

  • IHD
    • NSTEMI March ’20, PCI, converted to single antiplatelet therapy after 12/12
    • Admitted recently with unstable angina, possible lateral t wave changes but no trop rise. No angiographic findings suggesting revascularisation required. Some very distal LCA territory disease.
    • Recommenced on DAPT.
    • Ongoing daily GTN for angina at rest.
  • TTE shows mild apical hypokinesis and mildly reduced EF.
  • ? Anti-Phospholipid syndrome
    • Patient diagnosed at one stage as positive
    • Further review by different haematologist and repeat results suggest patient does not have APL syndrome

Discussion

  • Should surgery proceed?
    • GP encouraging patient to delay surgery, await further cardiologist review in 3/12
    • Cardiologist says patient may proceed with surgery now, happy for w/h of clopidogrel
    • Perioperative revascularisation reserved for lesions with a significant vascular territory (left main disease) or symptomatology. ? revasc not being offered despite daily symptoms, as not amenable to stenting.
    • Differential diagnosis:
      • Non-cardiac cause of chest pain due to essentially normal TTE in the setting of daily rest pain (e.g., recurrent PEs due to APL syndrome)
      • Non-anatomical cause for coronary ischaemic pain e.g., coronary artery thromboses from APL syndrome
  • ISCHEMIA trial showed that even with moderate to severe obstructive lesions, routine invasive therapy was not associated with a reduction in major adverse cardiac events compared to optimal medical therapy. (See attached article)
    • Patient leaning towards delaying surgery (which seems sensible from a purely elective surgery perspective) however, unlikely that anything will change before cardiology review to further guide the decision.
    • If surgery does proceed, patient may be a good candidate for postoperative troponin testing.
  • APL syndrome
    • Confusing picture with alternate haematologist views
    • Is perioperative Tranexamic acid safe? Brief literature search suggests, and group consensus was, that TXA use is not associated with increased risk of VTE in this setting.
    • ? impact on stent thrombosis risk

Plan:

  • Patient currently postponing surgery
  • When/if surgery planned in future, formal discussion with current haematologist  to ensure that the APL issue has been fully elucidated
  • Further discussion with treating cardiologist to guide postoperative monitoring/investigations given his IHD.

Endoscopies and pleural effusion

PIG Meeting: 24th June 2021

72yo male for gastroscopy and colonoscopy due to upper GIH and obstructive colonic symptoms

Background:

  • Presumed sarcoidosis (hasn’t attended F/U) with mediastinal adenopathy
  • ? metastatic lung malignancy. Previous effusion (? parapneumonic) drainage showed no malignant cells. Effusion now recurred. Nodules in lungs stable on repeat CT.
  • Severe cardiac disease
    • TTE 2021 (in context of admission for anaemia) Severely dilated left ventricle with severe RWMAs. EF 26%. Moderately dilated right ventricle with moderate systolic dysfunction. Moderate AS and AR. Mild to moderate MR. Moderately dilated atria. 
    • IHD – AMI ’09, PCI
  • PHTN – mod/severe at rest. 
  • TIA 2018
  • CKD
  • Ex-smoker

Issues:

  • SOBOE
    • Recent exercise tolerance reduction. Gentle incline, 100m, multiple breaks for SOB.
    • Orthopnoea.
    • ? malignancy
    • ? cardiac component to dyspnoea
  • Patient psychosocial issues
    • Difficult historian
    • DNA for multiple appointments and investigations previously
    • Patient declined face-to-face review in clinic
    • Surgical team unaware of multiple other complex issues

Discussion

  • Fit for endoscopies?
    • Greater issue is the benefit from these procedures. Diagnostic rather than therapeutic.
    • Surgical team has highlighted that if metastatic lung disease present, endoscopies may not need to occur
  • Optimisable?
    • Difficult to know from history alone.
    • Requires face to face review

Plan:

  • Admit for TTE (as unable to secure timely booking pre-admission)
  • Respiratory team will review while inpatient
  • Pending these reviews and pleural fluid drainage, endoscopies may proceed
  • Requires inpatient admission for bowel prep regardless due to multiple severe comorbidities

HBV in pregnancy, for elective Caesarean Section

PIG Meeting: 24th June 2021

33yo female for repeat CS

Background:

  • HBV – reactivated during pregnancy. Risk of vertical transmission
  • Albumin 30
  • Ferritin 45
  • Hb and platelet normal. 

Discussion

  • Implications of HBV in pregnancy
    • Not uncommon for reactivation due to immunosuppressive state of pregnancy
    • As per RANZCOG:
      • Method of delivery shouldn’t be affected by HBV status
      • Invasive procedures which may breech the maternal/foetal blood barrier should be avoided (e.g., foetal scalp clip)
      • Breast feeding is not contraindicated provided appropriate immunoprophylaxis has been given at birth.
      • With high viral load in third trimester, appropriate to commence antiviral therapy to reduce risk of transmission to baby
      • Arrangements for passive (HBIG) and active immunisation of baby need to be in place.
  • HBV testing
    • Noted that titres are reported in log multiples, therefore increasing levels represent exponential increase.
  • Universal precautions should be used. Patient will still have high HBV titres and therefore high infectivity at time of CS.

Elderly male, consultation for consideration of EVAR

PIG Meeting: 24th June 2021

83yo male with a 6.7cm aortic aneurysm. 

Background:

  • CAD
  • CABG + MVR 2009 – on warfarin
  • CCF EF 19%
  • COPD on home O2, ex-smoker
  • Severe Pulmonary HTN
  • Last TTE May 2021 – mildly dilated LV with severe global systolic dysfunction, severely dilated LA (volume 53mls/m2), well-seated mechanical mitral valve, severe pulmonary HTN (PASP 68), moderate TR, mild AR, EF 19%

Issues

  • Current inpatient with CCF exacerbation
  • Recent reduction in exercise tolerance
  • Referred to ED from perioperative clinic with SpO2 80% after 20m walk. NYHA class 4 dyspnoea.

Discussion

  • Should surgery proceed?
    • Life expectancy? Is he likely to die from his aneurysm or his cardiorespiratory comorbidities first (rupture rate for 6.7cm AAA is ~ 20% per year)
    • EVAR is a low physiologic stress procedure. 
    • Need clear documentation of ceilings of care (i.e., not for open procedure in emergency or if complications from EVAR)
  • Anaesthetic technique
    • GA may facilitate faster procedure and less IV contrast use (protecting from renal injury) due to improved immobility.
    • Can be done under LA/sedation if patient can lie flat/still and cooperate with breath holds

Plan:

  • Await outcome of current admission and liaise with surgical team (who are aware of admission)