PIG Notes 20th May 2021

Cases

• Elderly patient with recent stroke for dental clearance.
• Laparoscopic cholecystectomy and metastatic neuroendocrine tumour
• Deconditioned patient with metastatic lung cancer for parotidectomy
• TURBT with massive PE and LVOT obstruction
• Severe lung disease and caecal cancer
• Acute cholecystitis and right heart failure

52yo Aboriginal man. Referred to DA for Opinion- suitability for laparoscopic cholecystectomy or cholecystostomy.

Admitted to hospital with Chest pain, dyspnoea, and hypotension. Negative Troponin and CTPA. CT demonstrated calculous cholecystitis. Biliary sepsis with E-coli in biliary fluid.

Background:

• IDDM – on SGLT2 inhibitor
• AF with slow ventricular response
• PPM in 2013,  99% paced
• Obese ~110kg
• Living alone, independent ADL
• Ex-smoker

Issues:

Acute decompensation of chronic RV impairment during admission

• Worsening orthopnoea and dyspnoea, NYHA II->III
• Working diagnosis: sepsis-induced decompensation
• Echo – LV ok, MV/AV normal. RV- mod dilation, mildly D-shaped, Pressure and Volume overloaded. PAP peak 62mmHg. Hepatic vein flow reversal.
• CT- fibrosis and traction bronchiectasis.
• Decision made to proceed to Cholecystostomy via interventional radiology

Development of new Biventricular failure

• INR was noted to be 1.5 in setting of rivaroxaban therapy for AF
• Xa level normal
• Decision in conjunction with haematology to give 4 units of FFP
• Developed hypoxia and biventricular failure, requiring BiPAP

Worsening of Glycaemic control

• Sepsis
• Interruption to usual therapy

Discussion and Plan:

Timing and preparation for laparoscopic cholecystectomy

• Distance patient
• Plan is to be discharged with cholecystostomy tube in-situ
• Ideally patient shouldn’t have to travel to Newcastle multiple times
• Refer to regular cardiologist for review and repeat echocardiogram preoperatively
• Endocrine review – rapid access endocrine clinic offers telehealth

INR Reversal

• Difficult situation to navigate as driven by procedural team and appropriately consulted with haematology
• Prothrombinex may have been a superior choice in this situation due to less volume and increased effectiveness
• Regular anaesthetic list in interventional radiology, it may be useful to have a combined meeting/CME in order to gain mutual knowledge on the procedures and perioperative preparation
• Interventional radiology society guidelines on periprocedural anticoagulants discussed; https://irsa.com.au/consensus-guidelines-on-anticoagulants-in-ir/

79-year-old man for laparoscopic Right Hemicolectomy on a background of Caecal cancer

Background:

• COPD – Current Smoker
• Pulmonary Fibrosis – New diagnosis on staging CT
• Multiple previous abdominal surgeries including AAA repair and aorto-bifemoral bypass grafting
• Alcohol excess
• Impaired fasting glucose

Issues:

• Surgical concern regarding the potential difficulties or laparoscopic surgery and chance of having to open
• PFT’s – significantly reduced TLCO = 16% and FEV1/FVC = 0.53 in setting of COPD and new diagnosis of pulmonary fibrosis
• Asymptomatic, DASI = 5.8. Plays bowls

Discussion:

Epidural Anaesthesia

• High chance of conversion to open
• Multiple risk factors for postoperative pulmonary complications
• Consensus that there are many options for regional anaesthesia if converts to open surgery
• Preoperative discussion with surgeon to confirm best technique for analgesia

Disposition

• Ideally ICU 2 postoperatively given co-morbidities and likely long and difficult surgery/possible open procedure
• Would it be reasonable to proceed if no ICU bed available?
• Consensus was no, this patient should have post-operative HDU as a minimum standard of care

Plan:

• Proceed as planned
• Regional anaesthesia recommended, technique as per surgeon and procedural anaesthetist
• Postoperative ICU 2

82-year-old lady for Cystoscopy and TURBT on background of haematuria

Background:

• Previous spontaneous ‘Massive’ PE in 2014 and bilateral PE’s in 2016
• Provoked DVT many years ago – cancer
• On lifelong anticoagulation for PE’s
• Bowel cancer and splenectomy 1994
• Hypertension

Issues:

• Massive PE in March 2021 – haemodynamically compromised
• Had recently ceased NOAC due to haematuria. Was thrombolysed in ED
• ICU admission complicated by haemodynamic instability and AKI
• Echo during ICU admission showed Dynamic LVOT obstruction and queried severe AS

Discussion:

Echocardiographic Findings

• Echo done in the setting of haemodynamic compromise and tachycardia
• Repeat study ordered in clinic – no significant AS, Moderate AR, PASP 38mmHg, and septal angulation with increased velocity in LVOT related to AR
• Discussed at cardiology meeting – previous echo done in setting of acute unstable clinical state. Excellent demonstration of the effects of tachycardia and HD instability on the function of an already impaired heart
• Value in repeating echo in this circumstance
• Cardiologist recommends avoidance of tachycardia and ensure patient is adequately filled preoperatively

Timing of surgery

• Respiratory physician recommends 3 months post most recent PE
• Haematuria is ongoing but mild on anticoagulation
• Concerning regarding cessation of anticoagulation for surgery

Investigation of PE’s

• Cause never elucidated
• Previous Factor V Leiden and anticardiolipin antibodies normal
• No haematology review

Plan:

• Await ongoing respiratory advice
• Refer to haematologist

TOPIC 3:               Consult for Parotidectomy

69-year-old lady for potential resection of deep lobe of parotid – Likely carcinoma

Background:

• New Right parapharyngeal mass on surveillance PET
• Asymptomatic
• Non-small cell lung cancer – Stage IV with Brain metastases
• Complete response to palliative radiotherapy

Issues

• COPD, moderate disease FEV1/FVC = 0.6 (79%)
•  50 pack year smoking history
• Deconditioned +++
• 3.9 METS on DASI. Walks 20-30m with stick or 4WW
• Significant clinical depression with suicidal ideation
• Rarely leaves home

Discussion

Should surgery proceed?

• No Formal diagnosis of mass
• Discussion with surgeon at clinic – FNA arranged. If benign then for surveillance but if malignant will require resection which is a high-risk procedure due to proximity of vascular structures

Optimisation options

• No clinical issues identified to optimise
• Depression and deconditioning severely impacting functional capacity
• Prehabilitation – sometimes the social aspect can be beneficial in isolated people
• Distance patient – need to explore options
• GP manages significant depressive symptoms – is there any possibility of specialist input?
• Psychiatry and psychology services currently difficult to obtain

Plan:

• Await results of FNA
• Discuss with CPET team regarding referral to prehabilitation and role of CPET if surgery is to proceed
• GP letter to attempt to refer to psychiatrist and/or psychologist for review of mental health symptoms

64-year-old man for laparoscopic cholecystectomy following episode of acute cholecystitis.

Background

• Recent admission with acute cholecystitis

Issues

• Metastatic Neuroendocrine Tumour (Grade 1)
• Carcinoid syndrome
• Origin I terminal ileum with Liver and nodal disease
• Monthly Lantreotide – now stable disease
• Experiences flushing and palpitations if consumes alcohol
• ? Risk of carcinoid syndrome intraoperatively: Discussed with Oncologist. Uncertain regarding intraoperative risk. Indolent tumour therefore low risk assumed

Discussion

Difficult to determine risk of carcinoid

• Surgery needs to proceed, risk of further episodes of cholecystitis
• No options for optimization
• Consensus would proceed and have octreotide ready in room but not to give as prophylaxis

Plan

• Proceed to surgery
• Discussion with procedural anaesthetist
• Ensure current therapy not interrupted by surgery
• Octreotide infusion if develops symptoms

76-year-old man for upper dental clearance

Background

• Significant tooth decay and gum disease
• Affecting ability to eat and impacting on QoL
• AF – on Apixaban
• IHD
• OSA – CPAP
• Mycotic AAA – EVAR 2019. On lifelong clopidogrel
• NIDDM – HbA1c – 6.6%
• CKD

Issues

• Recent CVA – Feb 2021. Lacunar infarct of internal capsule and Thalamus.
• 3 previous CVA’s
• Dysphagia due to previous CVA.
• Dentition worsening oral intake and exacerbating symptoms
• Patient very keen for procedure to be done as soon as possible

Discussion

• Elective procedure
• Current evidence recommends elective surgery should occur 9 months post CVA for risk reduction (Perioperative stroke after non-cardiac, non-neurological surgery – BJA Education)

Ongoing ischaemic events on anticoagulation and anti-platelet therapy

• Will the risks be significantly reduced in this patient after 9  months?
• Other options – outpatient dental procedures are done on anticoagulant therapy, can he have some of his teeth out in the community while awaiting full dental clearance?
• Should Neurologist/Haematologist advice should be sought regarding the cause of the CVA’s and management of anticoagulation

Plan:

• Discussion with surgical team:                
  • Further review with regards to symptomatic management options.
  • Happy to extract teeth with uninterrupted clopidogrel therapy
• Liaise with neurologist and haematologist

PIG Meeting Notes

PIG Notes 13th May 2021

Cases

• Elderly, poor function for redo neck surgery
• Major orthopaedic surgery with metastatic melanoma
• Major orthopaedic surgery post recent PE
• JW patient for THR
• Elderly patient for C3/4 laminectomy
• Severe RHF and possible biliary colic

PIG Meeting: 13th May 2021

72yo male with subacute RUQ pain for ERCP and trans-cystic stent

Background

• Right heart failure with severe TR and dilated RV.
• Anaemia (Hb76) due to non-healing telangiectasia in the small bowel. Rpt Fe infusions. On EPO.
• Antibodies in blood therefore cross-matching extremely difficult/impossible.
• BMI 38
• OSA on CPAP
• NIDDM (controlled)
• HTN
• Difficult intubation
• Episode of non-sustained VT  during ERCP last year.

Issues

• RUQ pain
  • ? Due to liver capsule stretch v. Biliary colic
  • Severe, causing reduced QoL

• Severe RHF
  • Exacerbated by non-adherence to diuretics due to difficulties with frequent urination
  • Under a general physician who suggests patient is ‘as good as he gets’ (when adherent)

Discussion

• Should the procedure go ahead?
  • Complicated. Likelihood of benefit uncertain.
  • ? Warrants a period of high adherence to diuretics to see if pain resolves
  • PO diuretics may be poorly absorbed in severe RHF so ? IV in-patient trial warranted
  • Discussed further with physician – PO adequate, improved with adherence ++
  • QoL choice for the patient, with their values taken strongly into consideration, as this patient is essentially palliative.

• Anaesthetic technique?
  • PPV likely helpful physiologically in RHF. Hypercapnoea, hypoxia and subsequent increased PVR all poorly tolerated, so a controlled GA likely safest technique.
  • GA also avoids rapid need to manage known difficult airway in a prone, complex patient.
  • Patient recently had specialised endoscopic procedure (elsewhere) to evaluate his telangiectasia – plan to r/v those anaesthetic notes.

• If so, where should the procedure take place?
  • Endoscopy suite easier/faster for the proceduralist – has merit.
  • Endoscopy suite = distant from help.
  • Suggested that with pre-arranged additional skilled help (anaesthetic nurse and doctors) endoscopy suite likely ideal.

• Further optimisation possible?
  • Low risk of bleeding. Anaemia on maximal therapy regardless.
  • See above for comments from physician.

PIG Meeting: 13th May 2021

80yr old female

Background

• Tissue AVR
• AF

Issues:

• Missed cardiologist F/U
  • Missed annual TTE last year due to COVID issues
  • Previous TTE showed EF 40% (reduced from 50% the year before) and small paravalvular leak
  • DASI 6.6 METS
  • Plays golf weekly

Discussion

• Should surgery proceed without cardiologist F/U and TTE
• Group consensus was that with reasonable exercise tolerance as per DASI and daily activities, nil clinical e/o heart failure, reasonable to proceed as planned.