73yo male with a local recurrence of SCC around the cheek/infra-auricular area.
Background
- Facial SCC – WLE, neck dissection and radiotx March.
- DASI 6.6 METS
- PD – minor speech and swallowing changes
- Polycythaemia rubra vera – hydroxyurea and venesections q3/12
- Iron deficiency anaemia
- NHL – Chemotx, treated
Issues
- HOCM
- Known since 2016, mod on TTE
- Cardiologist review due to 6/12 history of worsening SOB
- SOB and angina with slight inclines
- TTE Aug ’21 showed severe LVOT obstruction, gradient 86mmHg
- Cardiologist commenced beta-blocker
- Ongoing review – Holter to look for ventricular tachydysrhythmias, ? will need defib, ? add disopyramide.
- Family to be referred for genetic testing
- Timing of procedure
- Ongoing cardiac workup and modification
- Surg team keen to avoid delays where possible, due to previous local metastasis
- Anaesthetic technique – surg reg suggests could be done under LA
- Airway
- Moderately difficult BMV and grade 2 laryngoscopy in March
- Patient notes reduced MO since radiotx
Discussion
- Anaesthetic technique
- LA spread may be unreliable due to previous surgery
- Concerns about sedation with likely difficult airway if conversion to GA required mid-case
- Low physiologic stress procedure. Stress not appreciably reduced by loco-regional technique rather than GA.
- HD stability desirable with HOCM
- Timing
- Thought that if Holter reassuring and asymptomatic from recent beta-blocker addition, then appropriate to proceed without delays to cancer surgery.
- Likely that the degree LVOT obstruction is unchanged since previous anaesthetic in March, which was well tolerated.
Plan
- Discuss Holter result with cardiologist – further treatment adjustment needed? disease severity likely stable since March.
- Notification of procedural anaesthetist – airway assessment and plan on DOS. Patient aware that AFOI may be required.
Perioperative Talk 