PIG Notes February 17th 2022

• Deconditioned, large hernia
• AKA after BAV
• Middle cerebral artery bypass
• EVAR and ? carcinoid
• MND and minor surgery

60yr old male with a large tender SCC on his chest.

Background:

• Motor neurone disease
  • Diagnosed 2011
  • Bed bound, wheelchair dependent
  • Bulbar palsy, cannot lie flat (will aspirate), requires suctioning even in semi-recumbent position
  • Full PEG feeds
  • Continuous BiPAP
  • Reasonable QoL, enjoys spending time with his supportive family
• Ex smoker
• IHD – AMI 2015, managed medically
• HTN

Issues

• Should surgery proceed
  • While this gentleman has limited life expectancy the lesion is painful and growing (currently ? 5x5cm)
  • Surgeon confident the procedure can occur under LA, including the graft donor site.
  • With both patient and surgeon very motivated to do the procedure under LA and to work under challenging conditions, high likelihood of success. 

• Advanced care planning
  • Complex discussion. Not previously documented or formalised by patient.
  • The patient would ‘like one shot at dying’ meaning if he is in a situation where he has substantially deteriorated he does not want active resuscitation.
  • However, he may consider brief periods of additional support (e.g. intubation) if he had deteriorated but not to the extent of, for example, losing consciousness, and if he had a chance to return to his current level of function and disability.
  • This is very fine distinction and requires ongoing thought from the patient between now and surgery, and further discussions between the anaesthetist and patient on the day of surgery.

• Level of postoperative care
  • Ideally this man will have his procedure under LA and return home to his well-supported home environment. No ICU bookings made.

Discussion

Motor neurone disease

• AKA amyotrophic lateral sclerosis
• Progressive dx characterized by degeneration of motor neurons within cortical, brainstem and ventral cord locations.
• Combination of upper and lower motor neurons involved.
• Focus of care is palliative and symptom control, including respiratory and nutritional support.
• Riluzole is an anti-glutamate medication used for symptom control

Perioperative pharmaceutical implications of MND

• Baclofen, diazepam and dantrolene may be used for spasticity
• Abrupt cessation of baclofen may cause an MH-like crisis.
• Avoid depolarising neuromuscular blockers
• Use heavily reduced non-depolarising neuromuscular blocker doses (and a PNS to guide use).
• Consider higher doses of rocuronium and sugammadex for PNS-guided full reversal.
• No association with MH, volatile anaesthesia safe to use.

Plan:

• Proceed to OT under LA
• Clinic anaesthetist to discuss with procedural anaesthetist once OT date and allocations known
• Aim to d/c home same day
• Further clarification of advanced care plan between procedural anaesthetist and patient

84yo male with 5cm AAA for EVAR

Background

• Nil CVS/RS dx
• Essential tremor
• MOCA 24/30
• Fungal sinusitis

Issues

? Carcinoid

• Recent hospitalization with severe pruritic rash, postural dizziness, flushing. Suggestion of carcinoid syndrome but no testing undertaken.
• Vascular surgeons happy to defer surgery given AAA 5cm, nil overly concerning imaging findings and asymptomatic
• Panel of biomarkers arranged
  • Serotonin, glucagon, VIP, urinary 5HIA, chromogranin A
  • Chromogranin A elevated (320) however PPIs and H2 antagonists can lead to elevations
  • Endocrinologists queried mastocytosis, however tryptase level was normal
• Endocrinologists said that the flush did not sound like a carcinoid flush and were confident that this did NOT represent carcinoid syndrome
• Rash biopsied (non-specific), commenced on an IL inhibitor for the rash. This medication (like many new monoclonal therapies) does not have an associated infection risk and does not need to be withheld perioperatively.

Plan

• Proceed with the EVAR

60+ year old male for a superficial temporal to middle cerebral artery bypass graft.

Background:

• Left MCA infarct 2017 and recurrent TIAs since, increasing in severity and frequency with a postural component
  • Terrible QoL, fear of episodes, worsening symptoms
• HTN
• PVD
• DM
• Laryngeal cancer – neck dissection, radiotherapy, laser. Residual dysphagia. Likley difficult airway.
• NH resident previously, now cared for by friend.
• CFS 6
• DASI < 4 METS. Wheelchair and walking stick for mobility

Issues

Surgical plans

• Internal carotid occlusive disease so not suitable for vascular surgical intervention
• Reviewed by registrar in the neurosurgical clinic and images/clinical history discussed with the surgeon (not reviewed by the surgeon in person)

Perioperative risks

• Above average for all risks using NSQIP scoring
• Particularly concerning is his risk of discharge to a care location (which the patient says is absolutely unacceptable to him)

Discussion:

Should surgery proceed?

• Concerning that for such a high risk surgery, the patient has not been reviewed by the surgeon directly

Have other causes/solutions to his syncopal events been explored?

• Holter requested by clinic anaesthetist
• Postural BPs and a trial of fludrocortisone could be a low risk investigation/intervention

Could this patient be optimised from a functional perspective?

• Very difficult for him to participate in prehabilitation due to his physical limitations from his hemiparesis.

Plan Patient re-reviewed by the neurosurgeon and deemed not suitable for this high risk procedure. Emphasises the importance of speaking to the surgical teams if you have concerns about the appropriateness of surgery.

68yo male with a smouldering periprosthetic knee infection considered unsalvageable, requiring AKA.

Background

• AF
• Large MCA stroke (likely embolic) while on rivaroxaban, since changed to warfarin. Residual hemiparesis.
• T2DM HbA1c 6.1%

Issues

• Severe AS
  • Previously known to be moderate.
  • Rpt TTE at anaesthetic registrar’s request while an inpatient several months ago awaiting AKA (delayed as patient was not mentally ready for the procedure).
  • TTE showed severe AS.
  • Patient had an aortic balloon valvuloplasty
  • Was due to have AKA soon after while off his anticoagulation however COVID resurgence delayed the procedure until now.

Discussion

Balloon aortic valvuloplasty

•  
  • BMJ best practice
    • First line therapy for clinically unstable patients or those with severe AS who require urgent non-cardiac surgery (due to the absence of requirement for anticoagulation, in contrast to aortic valve replacement, and the short recovery time)
    • Re-stenosis rates are high at 6/12
    • No proven mortality advantage however patients may have significant symptomatology and haemodynamic improvements, which may offer a window for more definitive care (if appropriate)
    • Mortality ~ 3% from the procedure
    • This patient’s AS was reduced to ‘moderate’ severity through the procedure.

• Grading AS
  • Classical descriptions using mmHg pressure gradient across valve and valve area
  • Dimensionless index useful. This is the ratio of the LV outflow tract (LVOT) time-velocity integral to that of the aortic valve jet. DI does not require the calculation of LVOT cross-sectional area, which is a cause of erroneous assessment and underestimation of AVA
  • This patient’s mean gradient did not meet the severe criteria but this may be due to LV failure (itself a sign of severe AS).

• Haemodynamic mx considerations under anaesthesia
  • CO is preload dependent – adequate filling P needed for non-compliant LV
  • Sinus rhythm with low normal HR needed for adequate filling time and LV myocardial perfusion.
  • High/normal SVR and DBP to maintain coronary perfusion.
  • Beware neuraxial -> drop in SVR and preload
  • Adequate analgesia to prevent catecholamine surges.

Plan:

• Proceed to OT

51yo lady with a large incisional hernia from her previous caesarean sections.

Background

• Asthma with 1 previous hospitalisation but recently well controlled
• Obesity BMI 38
• Hip/back pain
• Likely undiagnosed
• Ex-smoker (low PYH)

Issues

• Undifferentiated SOB
  • 20m on the flat, DASI 5 METS

• Surgeon would like patient to lose weight preoperatively, suggested prehabilitation
• Referred for CPET
  • AT 14ml/kg/min, peak VO2 16ml/kg/min
  • Formal lung function testing normal (nil e/o asthma/COPD)

Discussion

• Was ordering the CPET test appropriate?
  • Expensive resource
  • Indications include:
    • Major open surgery
    • Undifferentiated SOB
    • Intermediate surgery to provide assistance with risk stratification, discussions about invasiveness or appropriateness of surgery, and to determine postoperative level of care.
  • Thought that in this instance it may help to determine the cause of her SOB (now thought to be deconditioning) and to provide a guide for prehabilitation targets. CPET is not necessarily needed to guide prehabilitation.

• Plan from here?
  • While this patient is not considered high risk for surgery based on the CPET results, she could still be optimised in terms of fitness and weight reduction before this elective procedure

Plan

• Discuss the plan and goals with the surgeon
  • Surgeon said this is a wide-necked hernia with a low risk of incarceration or strangulation and so agreed to a delay of 8wks to optimise the patient’s weight and fitness.
• Referred for prehabilitation
  • The Kaden Centre is still offering home-based exercise programs which is ideal for this patient who lives at a distance. She is motivated to improve her fitness and has already lost 7kg in the last 2 months so is likely to do well with a program with limited supervision.
• CPET results will be forwarded to the GP, including the formal lung function studies, to guide them in future asthma-medication prescribing (which may not be indicated for this patient).

• Elderly, severe comorbidities, ? nephrectomy
• Positive sestamibi, ? EVAR
• Complex IHD, SPC v. TURP

Background:

• PVD
• CKD
• Nursing home resident, requires assistance with ADL’s
• DASI 2.6 MET’s

Issues:

• Complex IHD
  • CABG x2, all grafts blocked, multiple DES in grafts
  • Daily stable angina
  • Normal LV function with mild RWMA
  • Regular cardiologist review, optimal medical therapy, lifelong plavix
• Haematuria
  • Post IDC insertion in nursing home for urinary retention
  • On Clopidogrel at time
  • Imaging showed bilateral hydronephrosis and enlarged prostate

Discussion:

• High-risk for perioperative MACE
  • Bleeding risk
  • On optimal therapy
  • Will require cessation of antiplatelet agent perioperatively
• TURP
  • Longer procedure
  • Also consented for SPC – is this long or short-term?
  • TURP requires significant period of antiplatelet cessation
• Surgical discussion
  • Patient can have just the SPC as a permanent solution under LA, TURP may or may not render him catheter-free
  • Either option will require cessation of antiplatelets but much shorter duration for SPC
  • Final option would be to wait and see, patient will always need an IDC but if he is stable and happy with current situation then continue IDC changes in nursing home and organize surgical review in 6 months
• Patient discussion – the above discussed with patient and nurse, opted to continue with IDC and review in 6 months
  • Currently no issues with the IDC
  • Patient concerned about cardiac comorbidities

Plan:

• IDC to remain in situ
• Urology outpatient review in 6 months

81-year-old for Fenestrated EVAR.

Background:

• Juxtarenal AAA: 56x63mm
  • Complex procedure involving custom graft and sacrifice of left kidney via occlusion of L renal artery.
• Peripheral vascular disease – Left SFA stent 2011
• CVA – many years ago. Residual left arm and leg weakness
• Ex-smoker

Issues:

• IHD
  • ‘Silent’ MI in 2001
  • Sestamibi organised by surgical team as part of pre-op workup – LAD territory perfusion defect. Majority of defect is fixed but there is an area of low-grade reversible ischaemia
  • Echo shows normal LV size and systolic function. Mild segmental impairment.
  • Patient remains asymptomatic
  • Discussed at cardiology meeting – high-risk for perioperative MACE
  • Not a candidate for preoperative intervention given lack of symptoms, relatively normal LV function, and likely surgical CAD
  • Cardiologist advice was to proceed with surgery and contact perioperatively if any issues
• Surgical discussion – above information discussed
  • Surgeon feels cardiac risk is significant
  • Advises a further perioperative visit to relay risk and discuss cancellation of procedure
  • Difficulty contacting patient – Time an issue as surgery in a few days

Discussion: surgeon reluctance to proceed, do most pt’s EVAR candidates have ischaemia, 5% mortality per year, AKI likely

84-year-old lady with localised small central renal tumour

Background

• HTN
• COPD
• CKD

Issues

• Congestive cardiac failure
  • Recent hospital admissions with dyspnoea and significant decompemsation
  • NYHA class 4. Housebound, walks 20m on flat
  • Echo 2020: Mild pulmonary hypertension and mod-severe AR
• Recent echo – significant deterioration. Severe pulmonary hypertension; PASP = 66mmHg, dilated RV, Moderate MR, Moderate-Severe AR, Mod TR
• Respiratory component?
  • No formally diagnosed lung disease
  • Respiratory physician and spirometry organised and pending

Discussion

• Renal cell carcinoma
  • Very small cancer: 3cm, central so not appropriate for ablation currently.
  • Issues are local growth and bleeding.
  • Tumour progression and Metastatic disease usually occur very slowly.
  • There may be less invasive procedures available to address local symptoms/tumour may become amenable to ablation as it increases in size
• Significant risk of perioperative M&M
  • Patient states quality of life more important than quantity, happy to continue the way she is for the next year or longer
  • High risk of death from current cardiac disease and pulmonary hypertension
  • RCRI 2-3

Plan

• Surgeon has organised meeting with patient and family to discuss options for non-surgical management
• To continue with respiratory review – options for symptomatic improvement and optimisation for further, less invasive procedures