Category PIG Meeting Cases

Opioid weaning prior to THR

Gabrielle Morris

Background

  • CCF
  • Angina- DSE no inducible ischaemia
    • cardiologist cleared for TKR
  • NIDDM
  • Frailty
  • Chronic pain – hip and back
  • High dose opioid use -100mg/day morphine equivalent
    • Pain specialist letter recommends perioperative weaning as pain not opioid responsive.
    • Interventional pain procedure as alternate treatment organised previously – short-term relief only
    • Further interventional pain options possible, but pain specialist suggesting need for surgery to facilitate analgesia

Issues

  • Should we postpone for opioid weaning preoperatively – will the delay provide perioperative risk-reduction?

Discussion

  • Difficult situation – traditional push for opioid-weaning perioperatively to facilitate better postoperative analgesia
  • FPM seminar at ANZCA perioperative SIG (Dr Noam Winter):
    • Increased push for opioid weaning perioperatively can be problematic
    • Risk with sudden weaning or stopping opioids – withdrawal, depression, mental health decline
  • Consensus in the group that perioperative encouragement and liaison with pain specialist GP for Opioid rotation/ weaning appropriate
    • Must be under specialist supervision

Plan

  • Don’t delay surgery for weaning – Liaise with GP to commence opioid reduction plan preop to continue post operatively

Chronic hyponatraemia before vascular op

Gabrielle Morris

Background

  • Patient with hyponatremia ~129mmol/l chronically over years

Discussion

Plan

  • Await plasma and urinary sodium and osmolality
  • Follow up with endocrinology

Total laryngectomy and pectoralis flap

Gabrielle Morris

80yo F with haemoptysis and new diagnosis throat cancer 

Background:     

  • 5 previous neck dissections for head and neck SCC
    • Radiotherapy to neck
  • Frail – lives with husband and daughter
    • Independent ADL’s

Issues: 

  • New primary laryngeal lesion with local progression
    • ED presentation with haemoptysis requiring embolization
    • Ongoing haemoptysis
    • Hoarse voice, stridor in clinic
    • Chemotherapy commenced but ceased due to MSSA bacteraemia. 
  • Infective endocarditis from MSSA bacteraemia

Discussion

Appropriate to proceed to Surgery?

  • Palliative procedure in setting of ongoing haemoptysis and risk of airway obstruction 
  • Surgery may be futile – patient has advanced disease and is high-risk for perioperative morbidity and mortality 
  • NSQIP – increased risk across all variables but particularly functional decline and requirement for post-operative discharge to nursing facility
  • Mini-Cog:
    • Unable to complete clock drawing – numbers abnormally placed
    • Indicates cognitive impairment even if word recall is normal 
    • Uncertain as to interpretation of abnormality of specific clock drawings
  • Patient and family surprised at possibility of cognitive/ functional decline – wanted time to consider whether she wished to proceed

Non-surgical/less invasive options?

  • Surgeons came from theatre to have MDT discussion in periop clinic. Surgeon did not think offering tracheostomy was beneficial alternative over laryngectomy.
  • Discussed with oncology who were surprised surgery was offered 
  • Following day after clinic represented to ED with worsening haemoptysis and dyspnoea – told staff in ED she has decided not to proceed with OT

Plan:

  • Follow up with patient to link in with palliative care team

Bilateral TKR

Gabrielle Morris

50 yo man with complex co-morbidities for bilateral TKR’s

Background

  • HTN – BP 170/125 in clinic. Pt states this is high – usually in normal range
  • Asthma
  • Smoker 4g THC/ day
  • Ex IVDU methamphetamines and opioids (stopped meth for 2/12)

Issues

  • Dilated lateral ventricles with cerebral aqueduct stenosis following historical meningitis infection
    • Lost to neurological follow up and repeat MRI not performed
    • Non-specific symptoms – Long term memory issues. Headaches. 
    • Hypertension noted
  • Discussed with Neurosurgical team – Recommended MRI brain and cerebral flow studies to exclude obstructive hydrocephalus
    • Patient attended MRI – unfortunately radiology could not cannulate patient so test not performed 

Update: Bilateral TKR’s in an ASA 3 patient

  • Usually reserved for ASA 1 and 2 patients
  • Social reasons – This may be the only opportunity for this patient to access the surgery
  • Facilitate single hospital admission and rehabilitation given both knees are significantly affected 
  • Surgery booked for next week, after Easter holiday

Discussion

  • Literature shows some improved postoperative outcomes; cumulative decreased LOS, pain, costs, and improved rehabilitation. 
  • However – increased mortality and morbidity with bilateral cf unilateral, this increases further with increased BMI and ASA status
  • Many studies performed on ASA 1&2 patients!
  • Consensus statement from AOA recommends shared decision-making https://www.kneesociety.org.au/resources/AOA-AKS-Position-Statement-on-bilateral-tkr-2021.pdf
  • Not appropriate to proceed to surgery without MRI given potential contribution of cerebral pathology to balance and mobility issues

Plan

  • Re-attempt MRI with anaesthetic assistance for cannulation
  • May require postponement of surgery – difficult to have MRI done and reviewed before OT date with Easter long weekend

Hiatus hernia repair and gastroplasty

Gabrielle Morris

81 yo man for consideration of hiatus hernia repair to treat dyspnoea

Background

  • Large hiatus hernia – involving entire stomach and some omentum
    • Reflux controlled on PPI – no GI symptoms
    • Nocturnal dry cough

Issues

  • Fibrotic lung disease 
    • Retired mine worker
    • Regular Respiratory review: 
    • NYHA class 3 dyspnoea, 50m on flat 
    • PFT’s – TLCO 39% FEV1 70% pred 
    • Commenced antifibrotic medication day before perioperative review
  • Dyspnoea 
    • Limiting quality of life for patient – no longer able to garden
    • Independent in ADL’s
    • Dynamic component?
      • Objectively better functional capacity than reported by respiratory team – NYHA class 2/3
      • DASI 5 METS, walked from carpark to clinic without stopping including stairs
  • Ejection systolic murmur noted on examination – not previously documented. No recent echocardiograms

Discussion

  • Difficult to ascertain how much dyspnoea is attributable to hiatus hernia:
    • Multifactorial dyspnoea may not improve with this surgery
    • Possible it is attributable to underlying fibrotic disease.
  • Patient and family undecided – only keen to proceed if surgery likely to improve dysapnoea
  • Recurring question for in PIG
    • Systematic review paper found – 262 patients (see attached )
    • Results showed Improved FEV1 but not residual volume or DLCO
  • Echocardiogram required to assess degree of LA compression and AV structure/function
  • Article: Hernia (2023) 27:839–848 https://doi.org/10.1007/s10029-023-02756-5

Plan

  • Echocardiogram
  • Continue antifibrotic medication for 3 months until next respiratory review 
  • Re-review in perioperative clinic prior to decision whether or not to proceed

Open peripheral vascular op, severe CM and ESRD

Gabrielle Morris

57yo lady for femoral loop AV graft to provide vascular access for haemodialysis

Background:

  • ESRD on HD
    • 2nd to DM. 
    • Was considered for tplt but workup revealed unoptimised cardiomyopathy
    • Multiple attempts at AV grafting in her right arm, not suitable for graft on the other side due to previous axillary dissection for breast Ca. Currently dialysed via permacath.
  • DCM – EF 25% – due to IHD (LAD disease, unable to be grafted or stented), chemotherapy toxicity and uraemia.
  • Mild asthma – spiro unexpectedly poor in clinic – FEV1 45% predicted, incongruous with symptoms
  • Low ex tol secondary to PVD – claudication 500m (DASI 5.8METS – ? accurate)

Issues:

  • Patient concern about surgical risks (vascular complications, loss of limb)
    • ? non-surgical options such as transition to PD
    • ? duration of time can use permacath
  • Cardiomyopathy
    • Increased CO from graft, ? ability to tolerate with EF 25% and known IHD
    • ? optimized from cardiac perspective – not on Entresto, ? could have bivent PPM

Plan:

  • Complex situation needing MDT input – cardiologist, nephrologist and surgeon

Hypertension prior to surgery

Gabrielle Morris

39 yo man for hip arthroplasty – AVN of hip

Background

  • HTN
    • Medicated (3 agents) for 10 years
    • Known to endocrinologist
    • Normal renal artery scans
    • Patient didn’t complete ambulatory testing, however BP 177/114 in clinic. Asymptomatic 
    • Endocrinoloigst recommended plasma metanephrines, ACTH, cortisol, and plasma renin
  • BMI 30
  • Reports drinking 24 beers a week
  • Current smoker

Issues

  • ? management of preoperative HTN 

Discussion

  • Ensure TFT’s checked. Check fasting cholesterol – ? would meet criteria for statin therapy
  • POQI consensus paper (BJA, 122 (5): 552e562 (2019) doi: 10.1016/j.bja.2019.01.018)
    • Hypertensive therapy preoperatively doesn’t necessarily lower risk. 
    • No evidence regarding duration of BP control which may confer a risk reduction
    • ‘White coat’ HTN is common and ambulatory measurements or documented control by GP should be used to guide therapy and perioperative decisions, rather than BP recording on day of surgery (in asymptomatic patients)
  • Hypertension in periop clinic – if symptomatic, should send to ED but reasonable to refer to GP if asymptomatic
  • Commencement of antihypertensives in patients seen in clinic is at discretion of clinic doctor – must ensure appropriate follow up is arranged.

Plan

  • Recheck BP in 2/52, proceed to OT if controlled
  • Discuss at cardiology meeting – ? for statin