Author garychleung

Cardiology conflicting advice

garychleung

PIG Meeting: 11th March 2021

73 year old man for unicompartmental knee replacement

Background

  • Mild OA of knee, restricting ability to play golf
  • Good exercise tolerance. DASI 7 METS
  • IHD – stents in 2000 and 2008. No follow up or symptoms since
  • Type 2 diabetes. Excellent glycaemic control

Issues

  • Positive sestamibi – RCA territory. Report states “test in isolation puts the patient into the moderate to high-risk category for perioperative cardiac event.”
  • Asymptomatic for many years and also during sestamibi.
  • Minimal knee symptoms, limiting golfing only.
  • Discussed at cardiology meeting, Dr Collins recommended cardiology appointment and angiogram
  • Reviewed by different cardiologist at clinic, outcome was to proceed with surgery and have angiogram post-operatively

Discussion

  • Awkward situation!
  • Many valid points raised regarding appropriateness of test in first instance
  • Consensus was to proceed with surgery as clinic cardiologist has reviewed the patient face to face and made an objective clinical assessment.
  • Perioperative troponin – should we consider in this patient? Agreed that this was a valid consideration but not practical as there is no current consensus in JHH on where and how to treat if raised post-operative troponin.

Plan

  • Proceed to surgery
  • Discuss case with procedural anaesthetist
  • Consider BNP. Most agreed that patient has had adequate perioperative risk assessment adding BNP unlikely to change management at JHH.

TURP and Aspirin allergy

garychleung

PIG Meeting: 11th March 2021

Background

  • On clopidogrel for history of TIA but had no formal diagnosis.
  • Urology team requested to cease clopidogrel and replace with aspirin for perioperative period.
  • Patient states he had previous urticaria and dyspnoea while on aspirin. Surgical team then suggested he commence aspirin and anti-histimine

Discussion

  • Difficult to confirm diagnosis of TIA, no neurologist input
  • No other CVS risk factors and previously ceased clopidogrel for other procedures
  • Aspirin-exacerbated respiratory disease (AERD) and anaphylaxis to salicylates is not uncommon and should be taken seriously.

Plan

  • Consensus that it is prudent to cease clopidogrel and not commence aspirin in this case given the soft indication
  • Surgical commitment to ensuring the patient received adequate antiplatelet cover was noted and commended

Pregnant patient with pulmonary embolism

garychleung

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

garychleung

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

garychleung

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

garychleung

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

PIG Meeting: 18th February 2021

garychleung

PIG Meeting Notes

PIG Notes 18th February 2021

Cases

Knee replacement with abnormal SESTAMIBI

garychleung

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