PEG Tube insertion in Cystic Fibrosis Patient

PIG Meeting: 29th April 2021

22-year-old for a PEG tube insertion to supplement nutrition

Background

  • CF, end-stage disease
  • Lung transplant 2019. Complex post-operative period requiring ECMO
  • Lung rejection late 2020
  • Recent decision not to proceed to further lung transplant due to disease severity
  • NYHA class 4 dyspnoea, wheelchair bound. 24-hour oxygen. BiPAP for sleeping
  • Pancreatic insufficiency. IDDM
  • Protein C deficiency – bilateral DVT’s and SVC thrombosis. Anticoagulated with warfarin
  • Nutritional deficit, increased metabolic demand unable to be met due to dyspnoea and general exhaustion

Issues

  • CF team and patient requesting PEG to aid in nutrition and improve QoL
  • Patient extremely high risk for GA or even sedation
  • Would not be able to use BiPAP due to need for endoscopy
  • Already ceased warfarin on review at perioperative clinic
  • Very challenging case in a remote location

Discussion

1. Anaesthetic options

  • Local with minimal or no sedation. Use of high flow nasal prongs/THRIVE.
  • Is an open procedure an option? Would negate need for endoscopy and allow use of BiPAP
  • Patient engaged and keen to try under LA

2. Location of procedure

  • Procedural anaesthetist keen to move to theatre 10
  • Proceduralist prefers endoscopy
  • Difficult situation as endoscopy very remote but procedure likely to happen more efficiently there
  • Possible to organise additional anaesthetist support in endoscopy for this case

3. End of life discussion

  • Recent decision (less than a week ago) that lung transplant won’t be proceeding
  • Patient and her mother understand now that her life is very limited
  • No formal documentation of ceiling of care
  • Discussion with CF specialist, has an appointment the day after the procedure
  • Discussion with patient regarding limitations with anaesthesia care and unsuitability for ICU. Understands same and keen to try and have procedure with as little intervention as possible

Plan

  • Investigate possibility of open or radiologically guided procedure
  • Liaise further with CF team regarding end of life wishes. She has been cared for them for many years and it is a discussion that would be better performed by them.
  • Liaise with DA of day to allocate extra anaesthetist if procedure is in endoscopy suite

High risk PCI with Impella Device

PIG Meeting: 29th April 2021

74-year-old man for PCI to left main coronary artery prior to vascular surgery

Background

  • Intermittent claudication at 100m
  • Thrombosed popliteal artery aneurysm, requiring stent
  • CABG 22 years ago
  • Previous LAD stent, now totally occluded
  • Open AAA repair 5 years ago, uneventful
  • Lives independently on acreage. Active, Chops wood.

Issues

  • Elective review by vascular surgeon revealed exertional dyspnoea
  • Sestamibi organised by surgical team showed a significant area of reversible ischaemia
  • Cardiologist review, proceeded to angiogram
  • Previous LAD stent, now totally occluded. All coronary grafts blocked. Native vessels severely blocked.
  • If requires PCI it would be High risk– Left-main and LAD disease. Likely need rotablade with significant chance of impaired coronary perfusion and myocardial stunning.
  • LVEF = 25%
  • Cardiologist advised that if PCI is performed preoperatively, an Impella device would be required

Discussion

Indication for stress test?

  • AHA guidelines would indicate that no myocardial stress imaging is indicated
  • Patient can perform > 4mets and is relatively asymptomatic
  • Cardiologist opinion that medical management is appropriate given lack of symptomatology
  • PCI is requirement for further anaesthesia and vascular surgery
  • Vascular symptoms are limiting exercise tolerance

What is an Impella device and why is it used?

  • Impella is a centrifugal pump which acts as Left ventricular assist device
  • The device pumps blood from the LV into the ascending aorta at an upper rate of 2.5L/min
  • Percutaneously inserted via 14fr sheath into the femoral artery
  • Multiple indications including high risk PCI. See www.impella.com and Protect II trial.

Plan

  • Continue to present novel cases such as this to aid in dissemination of knowledge
  • Consider presentation at CME
  • Note vascular surgical patients have baseline higher risk of significant coronary artery disease

PCI under General Anaesthesia

PIG Meeting: 29th April 2021

Elective PCI in a man with known triple vessel disease.

Background

  • Wheelchair-bound man with muscular dystrophy
  • Uses BiPAP at home – for sleep and occasionally daytime (Pressures 19/12cmH20)
  • Proceduralist has booked for GA

Issues

  • Unable to lie flat, sleeps sitting upright at home. Consideration of ischaemic heart disease contributing to SOB.
  • Requires BiPAP if sleeping
  • Muscular dystrophy
  • Known TVD, Previous PCI with cardiologists only – stented 2 of the 3 vessels. Now proceeding to the third blocked vessel.

Discussion

  • Anaesthetic options discussed
  • BiPAP required at home, can we administer additional Oxygen via patients own machine?
  • Could use HFNP but unlikely to provide enough support given significant pressure on own machine
  • Option to borrow a BiPAP machine from ICU
  • Consensus that avoidance of a GA in this patient would be preferable
  • Uncertain about type of muscular dystrophy but would avoid use of depolarising muscle relaxants

Plan

  • Discuss with proceduralist, option for light sedation/no sedation in as elevated position as possible
  • BiPAP machine from ICU if needing supplemental O2, consider using own if no O2
  • Need some more information on muscular dystrophy and any issues with previous procedure

WPW?

PIG Meeting: 22nd April 2021

53-year-old lady for meniscal repair

Background:

  • History of open cardiac procedure/ablation in early 20’s for arrhythmia.
  • No medical records and patient uncertain of cardiac history
  • Sternotomy scar

Issues:

  • Recent new onset palpitations with presyncope
  • No cardiologist or GP review
  • Complex social history and knee injury making it difficult for patient to attend appointments
  • Difficult to ascertain history

Discussion:

1. Cause of original arrhythmia

  • Likely condition requiring ablation in age group is Wolff-Parkinson-white
  • Some suggestion of WPW in old notes on DMR
  • Could be any number of other conditions requiring ablation, SVT, AF

2. Management of current symptoms

  • ECGs from consult and 2019 reviewed (see below) and discussed – ? pre-excitation
  • How likely are arrhythmias to recur post-ablation or is it a second pathology? See abstract below – BMJ open (2019) – Discussion of recurrence rates after EP ablation and risk factors

Plan:

  • Await Holter monitor results
  • Contact GP for further information on original procedure
  • Discuss at cardiology meeting or refer to cardiologist with Holter results.

SLE and PVD for Neurosurgery

PIG Meeting: 22nd April 2021

71-year-old man for titanium cranioplasty following a traumatic subdural haematoma.

Background:

  • Recent long and complicated hospital stay
  • Iatrogenic bowel perforation leading to septic shock requiring ICU and vasopressors
  • Developed ischaemic limb on background of previous vascular stents and SLE
  • Had been on lifelong warfarin and Plavix.
  • Restarted on warfarin and aspirin on pre-discharge
  • Hit head in rehab, traumatic subdural requiring emergency craniectomy and a further ICU admission

Issues

  • Currently home, back on warfarin and aspirin
  • History of SLE with high titre of anticardiolipin antibodies.
  • Distance patient
  • Neurosurgical team requiring cessation of anticoagulation and antiplatelet therapy
  • Patient and wife very worried about cessation of anticoagulation then travel to hospital.
  • Patient states leg is still ‘dusky’

Discussion

1. How to best manage anticoagulation

  • Multiple competing interests
  • Vascular team happy for warfarin to be ceased from a stent perspective
  • Immunologist concerned regarding high thrombosis risk and advised shortest possible interruption of therapy.
  • Recommends patient should have a high INR target of 2.5-3.5 and should receive enoxaparin or heparin anticoagulation as per high-risk protocol
  • Haematologist agrees with immunologist and will consult as an inpatient.

2. Heparin vs Enoxaparin

  • Heparin may be preferable as will be inpatient
  • Neurosurgeon keen to cease warfarin 5 days preoperatively
  • Suggestion to keep warfarin going until admitted then reverse warfarin and commence heparin infusion
  • Good plan but dependent on bed availability, Enoxaparin can be given regardless

Plan:

  • Cease warfarin 5 days preoperatively.
  • Commence 1.5mg/kg Enoxaparin 1 day after ceasing warfarin
  • Admit to hospital 2 days preoperatively
  • Haematologist review as inpatient
  • Last dose Enoxaparin 24 hours preoperatively

Prehabilitation for knee replacement

PIG Meeting: 22nd April 2021

64-year-old lady for a Left TKR. Currently housebound and immobile following right TKR.

Background

  • Right TKR in 2018 complicated by femoral condyle fracture intraoperatively
  • Partial weight-bearing postoperatively and unable to participate in rehabilitation
  • Currently housebound, no physical activity
  • Multiple previous postponements from perioperative clinic and one cancellation on day of surgery for medical optimisation

Issues

  • Morbidly obese, BMI 50
  • Very complex social situation, husband working full time and is her carer
  • Bilateral rotator cuff tears – may not be able to use forearm support frame postoperatively
  • Attended rehabilitation last year and engaged well with services
  • Lost 30kg with diet and exercise program
  • Stopped attending due to distance – patient is from Taree and was travelling to Newcastle
  • Poor understanding of perioperative risk.
  • Patient and husband very keen for surgery to proceed

Discussion

1. Should surgery proceed?

  • High risk for postoperative complications including joint infection
  • Unlikely to be physically fit to participate in rehabilitation in current condition
  • Surgical team unaware of booking for surgery and thought ‘she hadn’t been cleared by anaesthetics to proceed.’

2. Can this patient be optimised preoperatively?

  • Immobility – re-engage with physiotherapy and rehabilitation services
  • Previous effective weight loss with dietician input, new referral
  • Social issues, is husband struggling to cope? Would help from outside the home alleviate some stressors?
  • Consider home modifications to help patient to manage ADL’s alone

Plan

  • Multi-disciplinary input required from physio, OT, dietician, and social work.
  • Review in 6 weeks

Supraventricular Tachycardia For TKR

PIG Meeting: 22nd April 2021

78-year-old lady with history of SVT.

Background

  • 40-year history of episodes of SVT
  • Self-limiting but symptomatic. Last episode March 2021, came to ED but had self-terminated
  • Reviewed by cardiologist 10+ years ago. Normal echo and angiogram.
  • On metoprolol, no decrease in frequency of episodes
  • Multiple previous surgeries with no issues

Discussion

1. Preoperative Investigations

  • Should we organise Holter monitor and cardiology review pre-op?
  • Useful in setting of deciding on requirement for post-operative telemetry bed
  • No cardiology review for many years, may be offered different therapy. See AHA algorithm below.
  • Treatment of SVT in perioperative setting discussed

2. Postoperative care

  • ? Cardiac monitoring required post-operatively
  • Telemetry bed may be preferred

Plan

  • Outpatient Holter monitor
  • Discuss at cardiology meeting with results
  • Consider telemetry monitoring post-operatively in consultation with Cardiology
  • Check electrolytes and TFT’s
AHA 2015: Ongoing management of SVT of unknown mechanism.
SHD, structural heart disease (including ischemic heart disease); and SVT, supraventricular tachycardia.

Toe Amputation Vs Hiatus Hernia Repair

PIG Meeting: 8th April 2021

78-year-old lady for amputation of 4 toes due to valgus deformity

Background

  • Long-standing valgus deformity of toes, limiting ability to wear shoes
  • Wheelchair-bound following complex ankle surgery on other foot
  • Hiatus hernia with significant symptoms including daily nausea and vomiting, waterbrash and a hoarse voice

Issues

  • Hiatus hernia repair scheduled for 4 weeks after foot surgery
  • Patient very keen to proceed with both procedures as scheduled

Discussion

  • Likely safer to defer foot surgery until after hernia repair
  • Patient is aware of risks and if wants to proceed then that is reasonable
  • Neuraxial anaesthesia is an option

Plan

  • Discuss with general surgeon as they may not feel that timing of the foot surgery gives adequate recovery time before hernia repair

Thoracoabdominal aneurysm repair and CSF drain

PIG Meeting: 8th April 2021

58-year-old lady for repair of a thoraco-abdominal aortic aneurysm

Background

  • Significant vascular disease; 4.8cm aortic aneurysm, renal artery stenosis of single functioning kidney
  • Mesenteric ischaemia requiring inferior mesenteric artery stent in 2020. On life-long Dual antiplatelet therapy (DAPT)
  • Ex-smoker, 40+pack year history
  • Active, no limiting symptoms. Works in aged care.

Issues

  • Surgeon requesting CSF drain insertion for spinal cord protection but would like patient to remain on DAPT. (See attached paper on CSF Drain for SC Protection)
  • Phone call to surgeon explaining that DAPT would need to be ceased in order to facilitate a neuraxial procedure
  • Significant surgical concerns for IMA stent patency if DAPT were to be ceased

Discussion

  • Discussed with haematologist, platelet transfusion would not be a solution
  • Multiple possible options presented including brief cessation of clopidogrel and insertion of drain day before. Issue of what to do when epidural catheter in and for removal discussed.
  • Tirofiban discussed due to its reversibility – limited experience  
  • Can the procedure be postponed allowing a longer time period between insertion of the IMA stent and cessation of DAPT?
  • Consensus that insertion of the CSF drain prophylactically while on DAPT would not be accepted safe practice

Plan

  • Issues discussed with surgeon. Agrees for clopidogrel to be ceased pre-operatively to facilitate CSF drain.