? Perioperative cardiac Ix

45-year-old lady for hysterectomy 

Background

  • Menorrhagia
  • Smoker – cigarettes and marijuana
  • Laparoscopic salpingectomy recently, no issues
  • Ex-IVDU
  • Ex heavy ETOH
  • Very difficult social situation

Issues:

  • Intermittent chest pain
    • Challenging history
    • Atypical and self-limiting
    • Weekly, Exacerbated by stress
    • DASI > 4 METs
    • Normal ECG, no other cardiac investigations
  • Asthma
    • NYHA class 3 dyspnoea
    • Regular Ventolin use
    • No admissions or steroids
    • Unable to afford preventer
    • Normal spirometry
  • Epilepsy
    • weekly seizures, improved from previous
    • GP managing as currently awaiting neurologist appt. 
  • Menorrhagia
    • Letter from gynaecologist – try progesterone therapy first
    • Uncertain as to why has been listed for surgery
    • Hb 120, ferritin 36

Discussion

Optimisation

  • Cardiac Stress Test indicated?
    • Difficult decision, low-risk surgery. 
    • Patient not keen for further investigations despite risks and benefits being outlined in clinic
    • GP has written medical certificate at patients request stating that chest pain is stress-induced and not angina-related.
  • Respiratory consult
    • Stable asthma
    • Not compliant with preventer therapy – encouraged to do same

Plan:

  • Discussion with GP regarding need for cardiac investigations
  • Discuss with gynae surgeon – elucidate reason for procedure. 
  • Smoking cessation
  • Recommence asthma preventer
  • Social work support

Anaphylaxis and subsequent surgery

70-year-old man for Second shoulder surgery 

Background:

  • Previous TSR – refractory hypotension intra-operatively
  • No response to metaraminol
  • Responded to small bolus and brief infusion of adrenaline
  • No other features of anaphylaxis
  • Surgery completed
  • Well postoperatively

Issues

  • Tryptases 7.3/10.3/5.4 – dynamic changes but not significant rise
  • Immunologist opinion that dynamic changes in tryptase make it difficult to exclude mast cell activity
  • Allergy testing – extensive tests performed including agents to which he had not been exposed
  • Several mild skin reactions to propofol, vecuronium, chlorhexidine, and tranexamic acid.
  • Nil reactions to other common allergens used on DOS
  • Normal IgE levels specific to chlorhex, morphine, and latex
  • Conclusion from testing – Avoid NMB used at time (rocuronium), use iodine instead of chlorhex. Avoid TXA if possible. Propofol most commonly irritant so safe to use.

Discussion:

  • Difficult situation
  • Non-allergic/Anaphylactoid – i.e., not an IgE mediated process? Not included in allergy testing 
  • See attached BJA article (doi: 10.1016/j.bjae.2019.06.002) on perioperative anaphylaxis
Diagram

Description automatically generated

Plan

  • Proceed with surgery and follow immunologist advice
  • Preoperative discussion with patient regarding above discussion

Complex capacity issue

20-year-old lady for Removal of wisdom teeth

Previous cancellation on day of surgery as declining OT

Background:

  • Ex-premature baby; 25 weeks
  • Mild developmental delay
  • Autism

Issues:

  • Attended hospital on day of surgery with her father, declining OT, and premedication
  • Previous traumatic experiences in theatre as a child, felt she was having medical procedures against her wishes.
  • Patient stated she doesn’t have any dental pain, doesn’t need or want to have teeth extracted
  • Father had signed consent form but is not official enduring guardian
  • Procedure was cancelled on DOS in accordance with the patient’s wishes 

Discussion

  • Formal assessment of capacity:
    • NSW health special disability referral team pathway
    • Temporary guardianship order granted. 
    • Lengthy process
  • Father struggling with this issue and prefers not to become guardian in this instance
  • No psychological or social support for those with PTSD to mitigate stressors of attending hospital/OT as there are for children.
  • Consensus that even if patient doesn’t have legal capacity, it will be very difficult to carry out minor (non-life or limb-threatening procedures) if patient not willing.
  • Premedication unlikely to improve situation as previously declined

Plan

  • Consider pre-hospital premedication
  • Preoperative psychology input
  • Liaise with procedural anaesthetist

Aspiration pneumonia, fundoplication

62-year-old lady for Laparoscopic Hiatus hernia repair /Fundoplication

Background

  • Epilepsy 
  • Right hemicolectomy – Iatrogenic Perforation post colonoscopy 
  • Significant mental health conditions – Bipolar affective disorder, PTSD, anxiety
  • Chronic back pain, known to HIPs. Using cannabis oil, no opioids.
  • Fe-deficiency anaemia

Issues

  • Symptomatic Hiatus Hernia/GORD/Oesophageal dysmotility
    • Recurrent aspiration pneumonia 
    • 5-6 admissions in last 2 years
    • Sleeps on bed wedge
    • Eating clear soups and fasting from 5pm.
  • Moderate COPD:
    • Formal PFTs: FEV = 1.34 (55%) DLCO = 42%
    • FEV1 in clinic significantly decreased from previous; 0.82 (39%)
    • Clinically not dyspnoeic 
    • DASI 3.9 METs. Independent with ADL’s
  • Pulmonary nodules – non-malignant, thought to be inflammatory

Discussion

Perioperative Optimisation

  • Recent spirometry indicates pulmonary function has deteriorated
    • sequelae of recurrent aspiration pneumonia?
    • Clinically no change
    • Clinic spirometry – often difficult to obtain good technique and therefore, accurate results
    • Formal PFT’s would be useful in this circumstance though unlikely to change management
  • Regular review by respiratory physician:
    • Optimised, LABA and 2 inhaled steroids
    • Concerned regarding recurrent aspirations and feels surgery should proceed 

Risk of postoperative pulmonary complications (PPC)

  • ARISCAT score = 13.3%, intermediate risk of in-hospital PPC
  • GUPTA – 13.7% risk of post-op pneumonia

Disposition

  • Open vs lap, unusual to have to convert to open procedure
  • If open, would need rectus sheath catheters and possible ICU 2
  • ICU 3 suitable for laparoscopic procedure planned

Plan

  • Formal respiratory function tests and discussion with physician if any change
  • ICU 3
  • Discuss with procedural anaesthetist

? Carcinoid

53 yo lady for EUA rectum/biopsy – rectal mass. Recent colonoscopy

Issues:

  • Potential neuroendocrine disease secondary to rectal mass – flushing, tachycardia, and sweats
  • PET-avid thyroid nodule as well.
  • Note: Patient thought she was peri menopausal.

Discussion:

  • Endocrine discussion – carcinoid? Chromograffin A – mildly elevated. Not significant and no increased risk of Carcinoid disease or syndrome as per endocrine and surgeon.
  • TSH – low 0.16. ? hyperthyroid. T3 and T4 pending. Would that be a reasonable explanation?
  • Any further tests required? Can we test to see if patient is menopausal – discuss with Gynae

Plan:

  • Free T3/T4 – normal 
  • FSH and LH – normal 
  • Discussed with endocrine : no further investigation or management indicated. Unlikely menopausal. 
  • Proceed to surgery. 

Severe OSA, tonsillectomy (adult)

41 yo for tonsillectomy

Background

Severe OSA, AHI 107, normally on CPAP

Morbid obesity – 56

IDDM – new diagnosis after recent presentation with Hyperglycaemic hyperosmolar syndrome (HHS) requiring ICU

Issues and discussion

  • ICU post-operatively?

Mixed central and obstructive sleep apnoea – higher risk as per literature and respiratory discussion.

Tonsillectomy in adults is painful. Opioids often required

  • Patient had ICU bed booked in clinic by a senior consultant. Surgeon had indicated that ICU bed not required.
  • Surgeon of the opinion that patients are usually much better post-operatively
  • CPAP post airway surgery – usually ok post tonsils. Not post sinus surgery.
  • Surgical preference on RFA is always helpful and if we are deviating from that it is helpful to communicate with surgeon. Note ICU beds are in demand at JHH, and patient may be cancelled or list delayed if no ICU bed available. 
  • Children post-tonsillectomy often go to PICU. Evidence is growing to show that this is unnecessary, regardless of AHI

Elderly patient, ? oesophagectomy

75 yo with oesophageal cancer

Background:

  • HTN
  • AF – CHADS-VASC 4
  • Binge drinker
  • Ex-smoker
  • NIDDM
  • Epilepsy – absence seizures

Discussion:

  • BP in clinic – 192/70
  • Discussed at CPET group – not taking medications as has no regular GP
  • Spirometry: Mild airflow obstruction, post BD change 28%. Consistent with asthma.
  • CPET – Peak VO2 low at 15.2ml/kg, AT 7.7ml/kg/min. T depression inferolaterally towards peak exercise.
  • Maximal stress test: HRmax – 85% predicted. This patient reached 82% predicted, RER – 1.15. This patient – 1.12. RER (VCO2/VO2)
  • Ventilatory reserve – MVV=FEV1x35, should have at least 20% reserve. Patient has encroached on his ventilatory reserve. HR also raised at this time which could suggest SV limitation. Note patient has not been taking bronchodilators.
  • NAC – surgery planned for 8 weeks post NAC. Concern that patient will significantly decompensate with chemo
  • Borderline – alcohol intake – unwilling to cut-down. Weight loss, non-compliant with medications
  • Social issues – no car, may not be able to participate in prehab, from isolated area
  • Prehab – multiple options. Dr Jen Mackney co-ordinates via CPET MDT and periop clinic. This patient would be better suited to a supervised program. 

Plan

  • Restart antihypertensives and bronchodilators
  • Formal stress imaging
  • Prehab and re-test preoperatively before deciding if fit for surgery.

Frail, fumigating facial SCC

85 yo man for excision of large fungating SCC from face

Background

Nursing home resident – lived alone on a farm until recently. Entered nursing home post-cataract surgery as found to be not coping at home

Dementia

Prostate cancer

CABG 1997. No follow-up. Asymptomatic but doesn’t exercise much

DASI 3.9

Issues

  • Very frail
  • Large resection – PET scan shows invasion into skull bone and numerous surrounding structures. Lymph node involvement, no distant mets 
  • Systolic Murmur
  • Functional capacity very difficult to ascertain

Discussion:

  • Surgical plan – palliative vs curative surgery and radiotherapy. 
  • Curative surgery – Resectable but involves all inferotemporal fossa and teeth, will need neck dissection and free flap. May require exenteration of eye especially for curative intent. Long operation 8+ hours
  • Palliative – will still require significant surgery and skin graft
  • Surgeons feel curative us preferable for this patient. Likely die from maxillary artery bleed if cancer erodes into artery. 
  • Has a mediastinal node – awaiting Endobronchial US guided biopsy in 4-6 weeks to determine if metastatic disease. IF metastatic, then not for surgery. 
  • Family – further discussion required. Family discussion in clinic highlighted that patient will unlikely return to baseline. Patient and family were hoping that current nursing home admission was temporary.
  • Stress imaging – unlikely to change management
  • Echocardiogram – no evidence of heart failure but has a murmur. Could consider a BNP to give an indication of the contribution of valvopathy as has been recommended by cardiolgy in the past. 
  • Post-operative delirium – very high risk given dementia.
  • No baseline cognitive assessment. No regular GP