? Capacity, declining surgery

Cancellation on day of surgery: 19-year-old for wisdom tooth extraction

Background

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

Issues:

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

Discussion

  • Formal assessment of capacity is required in this case. 
  • Consensus was that the patients reasoning was sound, and cancellation of the procedure was the correct course of action
  • Social work contacted and will attempt to facilitate capacity assessment and ascertain if there is a requirement for an enduring guardian
  • Social work will attempt to source NDIS funding for psychological support
  • Grey area in adults – no psychological or social support for those with PTSD to mitigate stressors of attending hospital/OT as there are for children.
  • Significantly, agreement that even if patient doesn’t have legal capacity, it is very difficult to carry out minor (non-life or limb-threatening procedures) if they are not willing.
  • Patient advocacy processes should be clearly laid out in these cases

Plan:

  • Await formal assessment of capacity
  • Face to face review of patient preoperatively

Alzheimer’s disease and ear SCC

Consult: 91-Year-old man for consideration of excision of ear SCC and possible temporal bone flap resection.

Background

  • Early Alzheimer’s dementia
  • No major cardiorespiratory co-morbidities
  • Chronic pain – previous issues with opioid analgesia exacerbating cognitive decline, stable on current regime of Ibuprofen, Paracetamol and PRN Oxycodone

Issues

  • Mild Alzheimer’s dementia – regular review by geriatrician over the last 4 years.
  • MoCA score 20/30. Montreal Cognitive assessment Tool. See www.mocatest.org
  • Lives independently with wife in a retirement village, happy with current QoL
  • SCC right ear, increasing in size despite previous resection

Discussion

  • Significant risk of both reversible and irreversible cognitive decline. 
  • Patient and wife understand this risk and are keen to proceed.
  • Non-surgical option would be radiotherapy however, patient lives rurally and would have to travel to Port Macquarie every day for treatment. 
  • Both patient and his wife feel that radiotherapy would be create significant stress to their current lives. 
  • Untreated SCC is an unpleasant disease with significant pain and lifestyle limitations

Plan

  • Proceed to surgery as planned 

Frail, polymorbid patient for gastrectomy

Consult: 77-year-old man for consideration of laparoscopic partial gastrectomy

Background

  • Recent hospital admission with Haemoglobin of 48, inpatient blood transfusion and iron infusion 
  • Imaging revealed distal gastric tumour, no metastatic disease.
  • Severe COPD
  • AF – NOAC
  • Asbestosis
  • Peripheral Vascular Disease – previous bilateral LL stents
  • CKD – Stage 1

Issues

  • Spirometry in clinic and subsequent formal PFTs showed FEV1 = 0.91 (39%), PEFR = 23%, FEF25-75%=16% predicted.
  • Recent Exacerbation COPD requiring steroid therapy
  • Troponin rise to 50 during last admission, associated with anaemia
  • Echocardiogram unremarkable
  • DASI 3.9 MET’s
  • CFS = 5. Scores greater than 3 indicate increasing risk of adverse perioperative outcomes. See Rockwood article on clinical frailty DOI:10.1503/cmaj.050051
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Discussion

  • Respiratory function very concerning, has stopped smoking and has regular reviews with respiratory physician. On optimal therapy.
  • Increased risk of postoperative pulmonary complications:
    • GUPTA Postoperative respiratory failure risk =13% and postoperative pneumonia risk= 19%. 
    • ARISCAT score: 45 = High Risk of post-operative pulmonary complications.
  • Aggressive pathology – opportunities for optimisation are time-limited
  • Consensus that an open procedure would not be advisable in this patient. Surgical team in agreement with this assessment but should revisit this discussion preoperatively

Plan

  • Further discussion with surgical team regarding meeting outcomes
  • Proceed with laparoscopic gastrectomy
  • ICU 2 postoperative bed

Malignant polyp for hemicolectomy

86-year-old man for consideration of laparoscopic right hemicolectomy

Background

  • Malignant Caecal Polyp = Not fully excised at colonoscopy
  • No evidence of metastatic spread
  • COPD – Last exacerbation 2018, required hospital admission
  • Type II MI in context of LRTI
  • AF – anticoagulated
  • Moderate MR 
  • Mild OSA

Issues

  • Exertional dyspnoea at clinic, spirometry showed severe obstruction with good bronchodilator response.
  • Chest pain, new symptom. Occurring weekly. No cardiology follow-up since 2018
  • Clinical Frailty scale 5
  • Advanced age
  • Perioperative risk assessment – NSQIP scoring above average for all variables including a 47% risk of functional decline and approx. 20 % risk of serious complications, discharge into care, and delirium. SORT score gives a 7% risk of death for an elective procedure

Discussion

Surgical options

  • Is there scope for repeat colonoscopy/further attempt at excision or a luminal-based procedure.
  • Disease prognosis –uncertain regarding expected progression of cancer.
  • If there is an increased likelihood of bowel obstruction, may expedite decision for surgery.

Increased Perioperative risk

  • Risks discussed with patient and his son at the clinic. They both expressed that the perioperative risks were too great for them to proceed. Patient currently has a reasonable quality of life and would not be accepting of functional decline.
  • Life expectancy calculated to be < 5 years. Discussion regarding online prediction tools for life expectancy and their use in complex perioperative decision-making.

Optimisation

  • Prehabilitation and pulmonary rehab would be excellent opportunities to optimize respiratory function
  • Non-invasive stress testing and an echocardiogram should be performed preoperatively.
  •  If attending prehab, we should initiate concurrent cardiac investigations. 

Plan

  • Formal PFT’s and respiratory review organized
  • Discussion with surgical team – prognosis and surgical options
  • Liaise with GP regarding prehabilitation via Kaden centre or pulmonary rehab
  • Non-invasive cardiac stress testing and echocardiogram
  • Re-review in clinic with results of above 

UPDATE – surgical discussion. Histology revealed likelihood of very slow tumour progression. Surgeon in agreement with patient that no further management required at this stage. GP to organise prehab/pulmonary rehab and cardiac testing.

Completion gastrectomy and splenectomy in polymorbid patient

70yo male for completion gastrectomy for cancer, with curative intent

Background

  • Gastric cancer
  • Previous partial gastrectomy for ulcerative dx (+/- complications)
  • Hypertension
  • Ex-smoker since 6/12, now vaping, 70PYH. Spirometry normal.
  • IHD – CTCA showed 50% LAD stenosis, minor RCA dx. LBBB on ECG. 
  • TTE: EF lower limit of normal and stage I diastolic dysfunction.
  • Rheumatoid arthritis on monoclonal Ab therapy, nil known neck involvement.
  • Cerebellar dysfunction due to previous heavy ETOH and boxing
  • Peripheral neuropathy isolated to soles of feet. Concern that chemoRx may exacerbate this, leading to significant reduction in function
  • DASI METS 6.6

Issues

  • Expected difficult surgery – Major surgery and hostile abdomen
  • Perioperative risks
    • CPET showed peak VO2 23ml/kg/min, AT 12ml/kg/min but oscillatory breathing.
    • NSQIP – death 10%, complications 20%, increased care needs 20%
    • Patient v. motivated to improve fitness. Using a home exercise bike.
  • Nutrition
    • 12kg weight loss
    • Linked in with dietician
    • Fe and albumin reassuringly normal
    • Now on Sustagen

Discussion

  • What is oscillatory breathing?
    • Also known as periodic breathing.
    • Can be seen at rest or with exercise.
    • Multiple suggested mechanisms (incompletely understood): circulatory delay, reduced CO, increased chemosensitivity, pulmonary congestion etc.
    • Predictor of poor prognosis with HF and sudden death. 
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  • Any further investigations needed?
    • ? BNP indicated given the oscillatory breathing.
      • TTE and cardiologist review suggest nil CCF so seems unlikely
      • High risk already acknowledged, so BNP would not provide improved risk estimation
  • Appropriate to proceed with surgery?
    • High perioperative risks acknowledged but patient is well informed.
  • Analgesia?
    • Hostile abdomen may make rectus sheath catheters difficult for surgeons to insert.
    • More lateral TAP catheters under US guidance may be a better option
    • EDB possible however there were mixed opinions at the meeting. The MASTER trial showed no significant difference in adverse morbid outcomes in high-risk patients undergoing major abdominal surgery with and without epidural anaesthesia. There is evidence of substantial benefit for those at risk of postoperative pulmonary complications with improved intra- and postoperative analgesia and a reduction in respiratory complications.
  • Postop care location? Long, complicated surgery in a patient with known severe comorbidities.

Plan

  • Prehabilitation if surgery is delayed allowing for NACT.
  • Nil further investigations 
  • ICU 2
  • Analgesia plans for discussion with surgical team on the day

STA-MCA bypass with severe uncontrolled HTN

46-year-old male with occluded left MCA

Background

  • Occluded MCA
    • Attempted stenting previously. Stent thrombosed intraoperatively, required thrombolysis
    • Progressive right sided weakness – recent onset
  • ? IHD
    • STEMI – angiogram showed only moderate diffuse disease
    • 2nd STEMI 2017 – angiogram showed spasm, resolved during PCI with intra-arterial vasodilator therapy
    • Regular cardiology review. Multiple therapies trialed for coronary artery spasm and hypertension
    • Patient cannot tolerate verapamil PO.
  • Grade 3 HTN
    • 200/110 in clinic. 
    • Since age 14yo. 
    • Symptomatic if SBP < 165. Dizzy and nauseated
    • Headache when SBP>240
    • Equal in both arms
    • Extensively investigated including renin-angiotension levels etc, no cause elucidated.
  • Non-smoker, no DM

Issues:

  • New ECG changes in clinic – TWI in I and V5-6 (? LVH although only mild LVH on recent TTE)
  • HTN unoptimised
  • Monthly chest pain – Responsive to GTN. 
  • Chest pain much improved since commencement of Diltiazem

Discussion

  • ​HTN
    • Symptomatic at values higher or lower than a specific range
    • Nil further perioperative management is indicated.
    • Neurosurgery team aware
    • BP targets post-op? Risk of hyperemic brain injury v. “hypotensive” infarct
  • Frequent CP
    • Given unremarkable angiogram findings, in keeping with coronary vasospasm
  • Level of postop care
  • ICU 2 vs 3
  • Postoperative BP will require close monitoring and control
  • Invasive BP measurement would be optimal
  • Ward setting unlikely to be suitable in first 24/48 hours

Plan:

  • Discuss with surgeons – “yes will need strict BP control and monitoring.”
  • ICU level 2 
  • Discuss new ECG changes with treating cardiologist
  • Notification of procedural anaesthetist
  • Continue all antihypertensives preop

Super morbid obesity for laparoscopic hysterectomy

26yo, 197kg, female with grade 1 endometrial cancer for laparoscopic hysterectomy after failed treatment with Mirena for endometrial cancer.

Background:

  • Endometrial cancer – being treated with mirena/curettes. 
  • Nulliparous woman, keen to have children, may do so via surrogate with egg donation.
  • 2 x previous same procedure – one under GA igel 5, one under sedation with THRIVE. Both nil issues
  • OSA
    • Overnight oximetry with ODI 48/hr and witnessed apnoeas. 
    • Did not attend for review by respiratory physician despite repeated attempts from team.
    • HCO3 and PaCO2 normal on ABG, so no e/o obesity hypoventilation
  • High BMI ++ 

Issues

  • Unoptimised OSA 
  • Severe obesity, weight gain despite dietician review.

Discussion

  • Surgical options?
    • Maximum allowable time frame before surgery to allow optimisation?
    • Will laparoscopic be possible – open surgery can be more difficult in this setting.
    • Surgeon has been learning a new per-vaginal laparoscopic technique but doesn’t feel comfortable enough to try it in such a challenging patient.
  • Weight reduction surgery possible?
    • Information for Sydney clinic previously provided to GP however with COVID issues and need for expedited surgery, seems unlikely this will procced before hysterectomy.
    • Local options?
    • Would weight loss allow her cancer to be downgraded or avoid the need for surgery due to reduced hyper-oestrogenic state? See attached summary article on obesity-related gynaecological cancers.
  • OSA optimisation possible?
    • Local guideline (currently under development) would suggest that without OHS pre-op optimisation of OSA is not needed, due to lack of evidence suggesting improved perioperative outcomes.
  • Level of post-op care? If surgery able to proceed laparoscopically, ideal for patient, allowing normal ward care.

Plan

  • Speak with gynae surgeon to determine maximal timeframe for optimisation
    • 2 months
  • Speak with local bariatric surgeon
    • Yes, surgery possible locally in the public system. Gastric bypass for “severe reflux” or sleeve gastrectomy if patient gains support from local MP.
    • Weight list ~12mths however this timeframe is used to develop rapport and engagement with the service’s dietician which is essential for postop success.
    • Letter sent to GP with this info.
  • Ensure patient referred to gynae-oncology dietician
  • Ensure patient has appointment with resp team.
  • Notification to procedural anesthetist once surgery date and allocations known.

Progressive mitochrondrial disease for SPC

68yo lady with progressive mitochondrial disease with neuropathic bladder, for botox injections, cystoscopy and SPC.

Background

  • Progressive mitochondrial disease
    • Looked after through mitochondrial dx clinic at RNSH
    • Mostly wheelchair bound
    • Nil known CVS/RS complications
    • Spirometry in clinic somewhat reassuring, values >50%
    • Not a variant strongly associated with refractory seizures
    • Nil reported dysphagia
    • Known to palliative care
  • HTN
  • Depression

Issues

  • Anaesthetic technique?
    • Above guidelines suggest:
      • Greatest perioperative risks derive from the severity of the patient’s pre-existing CVS/RS/CNS dx components
      • No specific anaesthetic technique or drug contraindicated
      • Not associated with MH
      • Chronic bowel dilatation and GI dysmotility puts these patients at risk of severe complications post-op due to opioids. Techniques to minimize opioids are ideal and prescribed bowel care necessary.
      • Baseline CK and lactate levels help to stratify severity of disease and to identify dynamic changes postop.
      • Increased VTE risk due to immobility

Plan

  • Proceed with surgery
  • Preop TTE as arranged by clinic
  • Group consensus was that a short acting SAB would be ideal (? Prilocaine) 
  • Procedural anaesthetist notified.

Severe IHD for H&N Cancer Surgery

82yo male for WLE of left and right ear lesions and right sided neck dissection. 

Background

  • IHD
    • NSTEMI Aug ’20 -> 2 x DES to LAD, 1 x DES to OM2, balloon angioplasty to OM1.
    • Angiogram for ongoing exertional angina June 2021 showed severe ostial LCx dx and PDA dx (70%)
    • Pt discussed at cardiology MDT, where possibility of CABG was raised.
  • Right facial SCC with metastasis to local nodes.
  • HTN
  • Dyslipidaemia

Issues

  • Difficulty communicating with the treating cardiologist
    • Cardiologist referred patient for recent angiogram, based on stable exertional angina
    • Cardiologist was happy for DAPT to cease for surgery but could not comment on whether further revascularization should occur before cancer surgery without reviewing the patient in person, which could not occur for several weeks.

Discussion

  • Should revascularization be considered?
    • Exercise tolerance very reassuring – mows lawns, 7.3 METS on DASI.
    • Further revascularisation (PCI or CABG) would require DAPT for a period, delaying cancer surgery.
    • Revascularization may be indicated for symptom relief, unlikely in this patient to provide survival benefit or reduced perioperative risk, based on current evidence (ISCHAEMIA trial)
  • What to do about difficulties with communication with cardiologist?
    • Discussion at cardiology-anaesthetic weekly MDT – previous experience of canvassing opinions of additional cardiologist. If patient already known to one cardiologist, can create uncertainty with conflicting opinions.

Plan

  • Attempt to contact cardiologist and emphasise desire to avoid delays to cancer surgery to wait for delayed in-person review.
    • Update: Contacted cardiologist, who advised that surgery should proceed based on reassuring TTE showing normal LV systolic fx and patient’s very good exercise tolerance.
    • Procedural anaesthetist to be updated on plan.