PIG Notes June 3rd 2021

Cases

• Multiple back surgeries and NSTEMI
• New diagnosis of neurofibromatosis in pregnancy
• Type 2 MI after THR
• Perioperative trifascicular block

72-year-old man for Lumbar Laminectomy

Background

• L5/S1 synovial cyst resulting in a radiculopathy.
• Severely limited by pain, unable to drive.
• Hypertension and hypercholesterolaemia
• CVA 12 years ago, on lifelong clopidogrel. No residual symptoms

Issues

• Phone consult, anaesthetist requested an ECG preoperatively
• ECG reviewed at a later date and Trifasicular block noted
• Patient denied any symptoms
• ECG discussed with cardiologist and decision made to proceed due to lack of symptoms
• Patient unable to make it to hospital on day of surgery due to floods
• Collapsed at home 2 days later and required emergency pacemaker insertion

Discussion

• Very interesting sequence of events!
• Perioperative assessment of distance patients via phone can present difficulties.
• In this case the ECG was viewed by a different anaesthetist at a later date but was still picked up and acted upon effectively.
• Patients may often have symptoms but are unaware or symptoms developed insidiously
• Discussion around risk of asymptomatic Bifasicular and Trifasicular block intraoperatively
• Majority of the opinion that there was significant risk of complete heart block
• AHA 2018 Guidelines on Bradycardia state; “In the setting of non-cardiac surgery, intraoperative bradycardia is most commonly attributable to SND and only rarely attributable to worsening atrioventricular conduction.”
• Recommendations do state that many anaesthetic drugs and surgical procedures can exacerbate existing bradycardia and should consider transcutaneous or Permanent pacing perioperatively
• AHA Management Algorithm for AV Block (2018)

63-year-old lady presenting for ORIF of a periprosthetic hip fracture

Background

• No significant past medical history. Current smoker.
• Elective total hip replacement 2 weeks prior to presentation
• Procedure performed as ‘Public in Private’
• Simple fall on discharge resulting in periprosthetic fracture

Issues

• Initial THR – Postoperative hypotension resulting in type 2 MI.
• Troponin rise to 900
• Required 5-day admission to ICU for vasopressor support, had profound vasoplegia
• Commenced on Aspirin and Beta-blocker
• Developed wound haematoma and had drop in haemoglobin, requiring transfusion
• Cardiologist review as inpatient, Echo unremarkable with normal LV function and no regional wall motion abnormalities
• For CTCA, not yet performed
• Patient experienced multiple issues due to being a public patient in the private hospital, clinical governance concerns

Discussion

Perioperative hypotension

• Uneventful intraoperative course with minimal blood loss
• On revisiting the history, patient stated she had a similar issue many years ago
• Uncertain cause – discussed possibility of undiagnosed pulmonary hypertension (not seen on echo), anaphylaxis unlikely, possibility it was a type 1 MI should be considered.
• Likely COPD, required bronchodilators during ICU admission.
• Current smoker, has cardiac risk factors.

Management of Current Procedure

• Emergent procedure, little value in CTCA preoperatively. Cardiologist in agreement.
• Postoperative troponin measurement – cardiologist opinion that it would be prudent in this case.
• Expectation that troponin will rise to around 800-900 but any further increases would warrant a cardiologist review
• CCU not an ideal location for post-surgical care, ICU bed more appropriate due to potential vasopressor requirement
• See above table from Canadian CV Guidelines

‘Public in private’ patients

• General opinion that patient selection for this criterion is complex and may not be being performed optimally at present
• Anaesthetists report they are encountering cases that are not suitable to be performed in some private hospitals  due to complex comorbidities, lack of postoperative monitoring etc
• Suggestion that it is important that we provide feedback on this issue, it may not be apparent to the relevant department.
• Concerns expressed regarding the movement of the patient between 3 different hospitals and subsequent discharge before completion of investigations
• Decision to discuss at M&M regarding clinical governance issues

23-year-old primip with incidental finding of Neurofibromatosis

Background

• MRI during pregnancy to assess potential foetal abnormality
• Noted lesions on maternal lumbar spine
• Maternal MRI performed showed ‘thoracic and lumbar spine lesions involving almost all the nerve roots…. Lesion at L3 extends into the spinal canal and deviates cauda equina to the left.’
• Differential diagnosis of Neurofibromatosis or schwannomas
• Asymptomatic, some intermittent back pain
• No skin lesions, vascular involvement, or hypertension

Issues

• Uncertain Diagnosis
• Reviewed by geneticist and awaiting phenotype results
• 37 weeks at time of review so may not have confirmed diagnosis by delivery
• Planned for vaginal delivery
• Patient keen for epidural anaesthesia

Discussion

Suitability for neuraxial anaesthesia

• Consensus opinion that neuraxial would be a safe option
• Epidural vs spinal – considering the lesion at L3 is causing significant compression of the dura, it may be difficult to feed an epidural catheter
• Likely that any neuraxial technique would have an increased likelihood of ineffective or patchy block
• Plan would be for an ultrasound-guided approach, performed early in labour, and a senior proceduralist.
• Space above L3 lesion recommended; L2/3
• See attached BJA article.

Neurosurgical opinion

• MRI reviewed, agree that neuraxial anaesthesia is safe.
• No brain lesions, therefore, no risk of herniation if Dural puncture
• Advice approach above or below L3

65-year-old man for a revision of a PLIF

Background

• Lung Transplant patient – pulmonary Fibrosis
• IHD, CABG in 2010
• IDDM
• Chronic Back pain with radiculopathy.

Issues

• L5/S1 PLIF 3 months ago
• Ongoing disabling back pain since procedure, resistant to multiple therapies
• NSTEMI 2 weeks postoperatively while in rehab
• Required urgent angioplasty and stent to RCA
• 10 days post MI, had S1 screw revision due to persistent pain
• Procedure performed on DAPT
• Persistent pain, surgical revision required due to unstable construct

Discussion

Timing of Surgery

• Consulted with treating cardiologist, increased length of RCA stent and therefore a higher risk of in-stent thrombosis
• Patient on DAPT and Apixaban
• Cardiologist would prefer to wait 3 months post PCI and then perform surgery on Aspirin
• Surgery urgent due to unstable construct therefore decision made to proceed.
• Clopidogrel and apixaban ceased preoperatively

Postoperative Disposition; ICU vs Telemetry bed

• Telemetry usually provides single lead monitoring and there may not be adequate ST segment assessment in this situation
• ICU can provide ECG and haemodynamic monitoring, with the additional benefit of haemodynamic support if required
• Decision may be affected by bed availability

Postoperative Troponin measurement

• Patient should have postoperative troponin measurements for 48-72 hours as per Canadian guidelines
• Discussion centred around management of increased Troponin in this case. Noted that increase troponin may be caused by non-cardiac conditions that require urgent intervention (eg PE or sepsis)
• DAPT will be recommenced as soon as surgical team happy bleeding risk is reduced
• Vision study: noncardiac surgery, peak postoperative hsTnT during the first 3 days after surgery showed significant correlation with 30-day mortality.
• https://jamanetwork.com/journals/jama/fullarticle/2620089

PIG Notes 27th May 2021

Cases

• TURBT with severe CCF
• Likely metastatic gastric cancer, ? futile procedure
• Arterial thromboses with platelet transfusion during emergency AAA
• OSA assessment and optimisation

Background

• Case study:
  • Obese female patient for laparoscopic gynaecological surgery.
  • Not optimised (non-compliant) on CPAP for known severe OSA
  • Conversion from laparoscopy to laparotomy due to surgical difficulty
  • Hypercapnoeic in PARU with imbalance between opioid requirements and respiratory drive.
  • Admitted to ICU overnight for observation and NIV
  • Recognised that day 3 (after ICU discharge) remains a high risk time for these patients, with resumption of normal sleep architecture and ongoing opioid requirements, leading to risk of opioid-induced hypoventilation and respiratory arrest.

Discussion

• Proactive perioperative efforts are leading to a large workload increase for the respiratory teams, with identification of so many patients at risk of severe OSA or with known OSA but not optimised.
• Long wait-lists for OSA assessment and management in the public health system (up to 12 months).
• New guideline being developed to identify the patients at highest risk perioperatively, to guide who should be referred to the respiratory teams, to maximise our use of this finite resource.

Background

• Recent patient, underwent emergency open AAA for rupture.
• 3 x MTPs used, with platelets as part of the 2nd MTP, as per local guideline.
• Survived initial surgery, went to ICU.
• Returned to OT later that day for bilateral lower limb arterial thrombectomies.
• Surgeon suggested that the use of platelets as part of the MTP in this setting may have contributed to the thromboses.

Discussion

• Should we be using different MTPs for major emergency vascular surgery?
  • BJA review article suggests a lack of high quality evidence to guide transfusion practices specifically in vascular surgery patients, but advocates for 1:1:1 transfusion protocols, the same as that used in trauma. https://academic.oup.com/bja/article/117/suppl_2/ii85/1744439
  • A small prospective single-blinded randomised study published in Transfusion Medicine found no increase in adverse events or survival impact from platelet transfusion in ruptured AAA patients before transfer to a tertiary centre for surgery. DOI: 10.1111/tme.12540
  • In elective AAA surgery, heparin is used prior to aortic cross-clamp to minimise the risk of arterial thrombosis. While seemingly counter-intuitive in the bleeding patient, should this be considered in emergency surgery also?
  • Blood transfusion is rapid and voluminous in emergency AAA surgery. Formal bloods results will be outdated by the time they are available and using TEG unless extremely familiar with it +/- with a dedicated technician can be distracting and time consuming.
  • Once the initial urgency has passed, restrictive transfusion strategies guided by results becomes more appropriate.

Overall it was felt that at this stage, sticking to current locally endorsed MTP guidelines is appropriate, however communication with the surgeon around appropriate blood product use is recommended.

88yo lady for repeat gastroscopy for confirmation of (suspected) gastric cancer.

Background

• ? Metastatic gastric adenocarcinoma
  • Weight loss ~30kg
  • Nausea, anorexia, abdominal pain.
  • CT abdo shows a thickened gastric wall suspicious for malignancy, with widespread lymph nodes and a peritoneal lesion suspicious for metastatic disease.
  • Gastroscopy April – large ulcer seen (H. Pylori +). Suspicious for malignancy but not found on histology/cytology.
  • Delirium lasting ~1/7 after gastroscopy.

• PEs – bilateral, diagnosed ~3wks ago. On therapeutic clexane.
• CKD + recent AKI, without return to baseline.
• Moderate aortic stenosis  2016
• Frail. Family assisting with all ADLs and using 4WW as wheelchair for most distances.
• Multiple recent ED presentations and hospital admissions with pain.

Issues

• What are the goals of care?
  • The patient seems to be dying, with symptoms and imaging consistent with metastatic gastric adenocarcinoma. Surgical team agrees this is the most likely diagnosis.
  • Surgeon says a formal cancer diagnosis would not lead to active treatment (chemo/surgery) due to her advanced age and frailty
  • Palliative radiotherapy might be considered if bleeding became an issue (not currently an issue).
  • Surgeon said that a diagnosis would assist with prognostication, dictating fast track palliative care v. Nursing home care for this lady.
  • Patient + family unaware that no active treatment was being considered.
  • Patient + family’s main priority was for symptom relief, which they were worried they needed a formal diagnosis to receive through pall care.
  • Concerns about deterioration after even a short procedure, given her frailty/active PEs/recent delirium, significantly reducing the length or quality of her remaining life.
  • GP very happy to manage this patient’s symptoms with palliative care in the community, although noted that pall care services are in her opinion, fairly limited.

Discussion

• Should the gastroscopy proceed?
  • Group consensus was that this is low yield healthcare as it provided no material change to her treatment plan.
  • Discussed the need for anaesthetists to see themselves not as technicians, providing services to proceduralists indiscriminately, but as active parts of the patient’s perioperative journey, with the ability to oversee/question/add value to the process.
  • Review booked with surgeon in 1/12.

• Midazolam use in the elderly – ? Contributes to delirium after endoscopic procedures.
  • Frequent use in large doses by procedural seditionists to minimise airway and haemodynamic complications.
  • ? The specific contribution of midazolam to delirium in elderly patients beyond that of change in environment, fasting, dehydration, surgical insult, pain, other anaesthetic agents, analgesics, acute illness, etc.
  • A recent small, prospective, observational pilot cohort study screened for delirium using the CAM tool in 40 patients who underwent elective endoscopic procedures. No patients were found to have delirium at 24-48h post procedure. https://doi.org/10.1186/s12871-021-01275-z

89yo male with known severe HFrEF and recurrence of bladder cancer causing haematuria and urinary retention.

Background

• Bladder cancer – previous TURBT (2019) and palliative radiotherapy. Symptomatic recurrence.
• Significant cardiac disease
  • Biventricular PPM for sinus-brady, PPM-dependent.
  • IHD – CABG 06, NSTEMI 18, angina 2-3x per week.
  • HFrEF, admitted with decompensation Nov ’20, EF~30%
  • PAF – anti coagulated.
• CVA post CABG (nil deficit)
• CKD eGFR 42
• Hypothyroidism
• Borderline exercise tolerance 4.6METS DASI
• Distant ex-smoker

Issues

• Severe HF + ongoing angina
  • Nil clinical e/o HF on examination.
  • Known severe dx, TTE relatively unchanged from 2018 – now.
  • Known to cardiologist, reviewed recently.
  • Discussed with that cardiologist – nil room for further optimisation.

Discussion

• Should surgery proceed?
  • Palliative procedure for symptom-relief
  • Low risk, low physiologic stress surgery.
  • Palliative radiotherapy an option? – possibly, but the patient cost (emotional, physical, QoL) of a weeks long course of daily radiotherapy at 89yo and with his comorbidities should not be underestimated. Overall seemed that the TURBT was the most patient-centred option.

• Any optimisation possible?
  • Cardiologist feels that patient is optimised. Further Ix/Mx of IHD would be invasive, low yield and may have secondary consequences with negative impact (such as delays to his symptom relief from TURBT; the need for additional anti platelet therapy which would cause further bleeding issues and be problematic in the perioperative period).