53 year old women for laparoscopy and removal of ovarian mass
Child pugh B liver cirrhosis secondary to hepatitis C
Ovarian mass with raised CA125
Seen in clinic in July 2021. Found to be in decompensated liver failure with ascites and right sided pleural effusion.
Discussed with surgeon. For 3/12 deferral only to optimize liver disease.
Recent diagnosis – hepatitis C
Decompensated liver failure
Coagulation tests deranged
Patient delayed 3 months – has completed treatment for Hepatitis C. Will have further pathology testing and liver ultrasound in follow up after surgery.
Liver decompensation – treated with diuretics. Patient refused treatment with lactulose. Resolution of ascites and right sided pleural effusion
Coagulation test derangement – common in liver disease, note that bleeding is related to abnormal anatomy (oesophageal varices, gastric/duodenal ulcers) and not necessarily coagulopathy. Current INR = 1.4, platelet count = 60.
Is TEG useful to help guide management of bleeding? Discussion about it’s use before and/or during surgery.
What treatment should be given for abnormal coagulation studies prior to surgery?
Should she have regular Vitamin K?
Patient discussed with surgeon as did not have date as yet. Surgeon was grateful for call as there was limited availability of operating time and this patient’s outcome may be affected by further delay to surgery.
Discussed with Haematology – they suggest that patient is unlikely to be coagulopathic. They state that recently released guidelines do not recommend platelet transfusion below levels of 50 in chronic liver disease who are not overtly bleeding, and that any FFP replacement is unlikely to significantly lower INR below 1.4 and not recommended in chronic liver disease (see DOI: 10.1111/jth.15562)
Vitamin K seems low risk – especially given orally, although not recommended in guidelines attached.
TEG in cirrhosis – seems promising, although patients seem to have variable results. See extract from recent review, with conclusions below.
Bilateral pitting peripheral oedema. Complaining of orthopnoea and PND.
DASI – 3.97, limited by fatigue
severely dilated LV and LA
MR with prolapse
Returned to clinic this week for PPM insertion
Thyroid function checked:
TSH = 8 hypothyroidism.
on thyroxine but not checked regularly
Echo repeated due to oedema, orthopnoea, and PND:
Normal Aortic Valve. No stenosis!
Does patient need PPM?
Likely that symptoms be attributed to hypothyroidism
Imperative that hypothyroidism is addressed first
Medication compliance issue should be considered
Timescale for expected changes with treatment of hypothyroidism.
weeks for improvement of symptoms
3 months for biochemical changes
Important to look at clinical picture as well as biochemistry when making decisions regarding fitness for surgery
Current clinic guidelines for TFT’s:
‘Monitoring is usually performed serially by GP. Consider testing peri-operatively if not done within 12 months if stable disease or sooner if frequent medication changes required/new cardiac arrhythmias/or signs and symptoms of thyroid disease.’ www.perioptalk.org
If request TFT’s will only get TSH value and need to request T3/T4 separately if required or if TSH abnormal
Need to revisit cardiac imaging – possibility of error with previous echo regarding documented AS
Discuss at Cardiology MDT – ideal place to consolidate this information and facilitate liaison with regular cardiologist
Postpone for 6 weeks
Review perioperative guidelines for Thyroid Function testing
49yo female with a large breast cancer requiring mastectomy.
Anorexia, known to a psychiatrist and a GP with a specific interest in eating disorders
Excellent exercise tolerance
Major depression, previous self-harm, and suicidal ideation
Recent 300kcal/d intake causing 4kg weight loss, BMI down to 16.5, associated with pedal oedema
Initial plan for preop admission to CMN under gastroenterology, with nearby psych support, for NG feeding to improve nutritional state.
Patient has declined this and has cooperated with increased intake at home (up to 1500kcal/d at present) with associated weight increase and improved exercise tolerance (runs for exercise)
Recent pathology normal
Patient requesting bilateral mastectomy and reconstruction to occur at same time as feels she will not cope psychologically with mastectomy.
Patient has expressed she does not want the surgeon to speak with psychiatrist
Has this patient’s psych history and current status been fully elucidated?
Alarming that she has declined surgeon and psychiatrist multidisciplinary discussions.
Is the psychiatrist fully aware of the current issues and plan?
Surgeon should attempt to gain approval from patient to speak with psychiatrist. Explain this to the patient in terms of our standard practice for liaison with specialist in any chronic health condition.
Provide patient with a framework for the proposed conversation to allay concerns about privacy regarding mental health history.
Advanced plan for deterioration is required and psychiatrist should be involved.
GP to act as intermediary as a second-line plan.
Should this patient have a mastectomy or a bilateral mastectomy with immediate reconstruction
Appropriate to proceed to surgery if patient continues current trajectory.
Surgeon will consider bilateral mastectomy and reconstruction given significant mental health history
Surgeon has advised that mastectomy without recon is preferable from a wound-healing perspective. High risk for wound breakdown, implant loss, and implant infection (especially if non-adherent to nutrition plan postop)
Mastectomy can be extremely distressing, even to psychologically well women.
Implant loss and wound breakdown are also very distressing.
Infection is relatively easily managed with removal of implant (temporarily or permanently) and IV Abx.
Perioperative concerns with anorexia
Multiple body systems affected (see review article)
Bulimic variant is more physically damaging and may be further complicated by cardio/myotoxicity from emetogenic medications.
Risk of cardiac dysrhythmias and fluid overload due to cardiac changes.
Other concerns – pressure area/nerve injury risks, active warming of patient and fluids needed, abnormal gastric emptying (assume unfasted), abnormal responses to NDMRs, concurrent drug or ETOH abuse (including amphetamines for weight loss), concerns about plasma levels of certain drugs which have a high unbound fraction if albumin is low.
Where should surgery take place
Public hospital with on-site psychiatric support seems most appropriate in event of psychological deterioration postop.
Risk of malnutrition and surgical complications will persist for weeks or even months postop.
If baseline ECG normal, nil evidence of dysrhythmias intraoperatively, and normal electrolytes, normal ward-based care is appropriate afterwards.
A plan should be in place for daily electrolyte monitoring and telemetry should derangement occur.
Reasonable to proceed with reconstruction from a purely physiologic perspective, given current nutrition status.
Surgeon to attempt to gain consent from patient to speak with psychiatrist.
Consider involving psychiatry liaison service while patient admitted, for mental health wellbeing monitoring.