PIG Meeting: 29th April 2021

Elective PCI in a man with known triple vessel disease.

Background

• Wheelchair-bound man with muscular dystrophy
• Uses BiPAP at home – for sleep and occasionally daytime (Pressures 19/12cmH20)
• Proceduralist has booked for GA

Issues

• Unable to lie flat, sleeps sitting upright at home. Consideration of ischaemic heart disease contributing to SOB.
• Requires BiPAP if sleeping
• Muscular dystrophy
• Known TVD, Previous PCI with cardiologists only – stented 2 of the 3 vessels. Now proceeding to the third blocked vessel.

Discussion

• Anaesthetic options discussed
• BiPAP required at home, can we administer additional Oxygen via patients own machine?
• Could use HFNP but unlikely to provide enough support given significant pressure on own machine
• Option to borrow a BiPAP machine from ICU
• Consensus that avoidance of a GA in this patient would be preferable
• Uncertain about type of muscular dystrophy but would avoid use of depolarising muscle relaxants

Plan

• Discuss with proceduralist, option for light sedation/no sedation in as elevated position as possible
• BiPAP machine from ICU if needing supplemental O2, consider using own if no O2
• Need some more information on muscular dystrophy and any issues with previous procedure

PIG Meeting Notes

PIG Notes 22nd April 2021

Cases

• Supraventricular Tachycardia For TKR
• Prehabilitation for knee replacement
• SLE and PVD for Neurosurgery
• WPW?

PIG Meeting: 22nd April 2021

53-year-old lady for meniscal repair

Background:

• History of open cardiac procedure/ablation in early 20’s for arrhythmia.
• No medical records and patient uncertain of cardiac history
• Sternotomy scar

Issues:

• Recent new onset palpitations with presyncope
• No cardiologist or GP review
• Complex social history and knee injury making it difficult for patient to attend appointments
• Difficult to ascertain history

Discussion:

1. Cause of original arrhythmia

• Likely condition requiring ablation in age group is Wolff-Parkinson-white
• Some suggestion of WPW in old notes on DMR
• Could be any number of other conditions requiring ablation, SVT, AF

2. Management of current symptoms

• ECGs from consult and 2019 reviewed (see below) and discussed – ? pre-excitation
• How likely are arrhythmias to recur post-ablation or is it a second pathology? See abstract below – BMJ open (2019) – Discussion of recurrence rates after EP ablation and risk factors

Plan:

• Await Holter monitor results
• Contact GP for further information on original procedure
• Discuss at cardiology meeting or refer to cardiologist with Holter results.

PIG Meeting: 22nd April 2021

71-year-old man for titanium cranioplasty following a traumatic subdural haematoma.

Background:

• Recent long and complicated hospital stay
• Iatrogenic bowel perforation leading to septic shock requiring ICU and vasopressors
• Developed ischaemic limb on background of previous vascular stents and SLE
• Had been on lifelong warfarin and Plavix.
• Restarted on warfarin and aspirin on pre-discharge
• Hit head in rehab, traumatic subdural requiring emergency craniectomy and a further ICU admission

Issues

• Currently home, back on warfarin and aspirin
• History of SLE with high titre of anticardiolipin antibodies.
• Distance patient
• Neurosurgical team requiring cessation of anticoagulation and antiplatelet therapy
• Patient and wife very worried about cessation of anticoagulation then travel to hospital.
• Patient states leg is still ‘dusky’

Discussion

1. How to best manage anticoagulation

• Multiple competing interests
• Vascular team happy for warfarin to be ceased from a stent perspective
• Immunologist concerned regarding high thrombosis risk and advised shortest possible interruption of therapy.
• Recommends patient should have a high INR target of 2.5-3.5 and should receive enoxaparin or heparin anticoagulation as per high-risk protocol
• Haematologist agrees with immunologist and will consult as an inpatient.

2. Heparin vs Enoxaparin

• Heparin may be preferable as will be inpatient
• Neurosurgeon keen to cease warfarin 5 days preoperatively
• Suggestion to keep warfarin going until admitted then reverse warfarin and commence heparin infusion
• Good plan but dependent on bed availability, Enoxaparin can be given regardless

Plan:

• Cease warfarin 5 days preoperatively.
• Commence 1.5mg/kg Enoxaparin 1 day after ceasing warfarin
• Admit to hospital 2 days preoperatively
• Haematologist review as inpatient
• Last dose Enoxaparin 24 hours preoperatively

PIG Meeting: 22nd April 2021

64-year-old lady for a Left TKR. Currently housebound and immobile following right TKR.

Background

• Right TKR in 2018 complicated by femoral condyle fracture intraoperatively
• Partial weight-bearing postoperatively and unable to participate in rehabilitation
• Currently housebound, no physical activity
• Multiple previous postponements from perioperative clinic and one cancellation on day of surgery for medical optimisation

Issues

• Morbidly obese, BMI 50
• Very complex social situation, husband working full time and is her carer
• Bilateral rotator cuff tears – may not be able to use forearm support frame postoperatively
• Attended rehabilitation last year and engaged well with services
• Lost 30kg with diet and exercise program
• Stopped attending due to distance – patient is from Taree and was travelling to Newcastle
• Poor understanding of perioperative risk.
• Patient and husband very keen for surgery to proceed

Discussion

1. Should surgery proceed?

• High risk for postoperative complications including joint infection
• Unlikely to be physically fit to participate in rehabilitation in current condition
• Surgical team unaware of booking for surgery and thought ‘she hadn’t been cleared by anaesthetics to proceed.’

2. Can this patient be optimised preoperatively?

• Immobility – re-engage with physiotherapy and rehabilitation services
• Previous effective weight loss with dietician input, new referral
• Social issues, is husband struggling to cope? Would help from outside the home alleviate some stressors?
• Consider home modifications to help patient to manage ADL’s alone

Plan

• Multi-disciplinary input required from physio, OT, dietician, and social work.
• Review in 6 weeks

PIG Meeting: 22nd April 2021

78-year-old lady with history of SVT.

Background

• 40-year history of episodes of SVT
• Self-limiting but symptomatic. Last episode March 2021, came to ED but had self-terminated
• Reviewed by cardiologist 10+ years ago. Normal echo and angiogram.
• On metoprolol, no decrease in frequency of episodes
• Multiple previous surgeries with no issues

Discussion

1. Preoperative Investigations

• Should we organise Holter monitor and cardiology review pre-op?
• Useful in setting of deciding on requirement for post-operative telemetry bed
• No cardiology review for many years, may be offered different therapy. See AHA algorithm below.
• Treatment of SVT in perioperative setting discussed

2. Postoperative care

• ? Cardiac monitoring required post-operatively
• Telemetry bed may be preferred

Plan

• Outpatient Holter monitor
• Discuss at cardiology meeting with results
• Consider telemetry monitoring post-operatively in consultation with Cardiology
• Check electrolytes and TFT’s

PIG Meeting: 8th April 2021

78-year-old lady for amputation of 4 toes due to valgus deformity

Background

• Long-standing valgus deformity of toes, limiting ability to wear shoes
• Wheelchair-bound following complex ankle surgery on other foot
• Hiatus hernia with significant symptoms including daily nausea and vomiting, waterbrash and a hoarse voice

Issues

• Hiatus hernia repair scheduled for 4 weeks after foot surgery
• Patient very keen to proceed with both procedures as scheduled

Discussion

• Likely safer to defer foot surgery until after hernia repair
• Patient is aware of risks and if wants to proceed then that is reasonable
• Neuraxial anaesthesia is an option

Plan

• Discuss with general surgeon as they may not feel that timing of the foot surgery gives adequate recovery time before hernia repair

PIG Meeting: 8th April 2021

58-year-old lady for repair of a thoraco-abdominal aortic aneurysm

Background

• Significant vascular disease; 4.8cm aortic aneurysm, renal artery stenosis of single functioning kidney
• Mesenteric ischaemia requiring inferior mesenteric artery stent in 2020. On life-long Dual antiplatelet therapy (DAPT)
• Ex-smoker, 40+pack year history
• Active, no limiting symptoms. Works in aged care.

Issues

• Surgeon requesting CSF drain insertion for spinal cord protection but would like patient to remain on DAPT. (See attached paper on CSF Drain for SC Protection)
• Phone call to surgeon explaining that DAPT would need to be ceased in order to facilitate a neuraxial procedure
• Significant surgical concerns for IMA stent patency if DAPT were to be ceased

Discussion

• Discussed with haematologist, platelet transfusion would not be a solution
• Multiple possible options presented including brief cessation of clopidogrel and insertion of drain day before. Issue of what to do when epidural catheter in and for removal discussed.
• Tirofiban discussed due to its reversibility – limited experience  
• Can the procedure be postponed allowing a longer time period between insertion of the IMA stent and cessation of DAPT?
• Consensus that insertion of the CSF drain prophylactically while on DAPT would not be accepted safe practice

Plan

• Issues discussed with surgeon. Agrees for clopidogrel to be ceased pre-operatively to facilitate CSF drain.

PIG Meeting: 8th April 2021

63-year-old lady normal pressure hydrocephalus.

History of headaches and dizzy spells.

Background

• IDDM with suboptimal glycaemic control, HbA1C = 12%
• On 110 units of Ultra-long and rapid-acting insulin per day
• Previous endocrine reviews reveal poor glycaemic control over many years
• Compliant with medications but doesn’t have a glucometer
• No known diabetic complications but history difficult due to neurological symptoms
• COPD – NYHA 3 dyspnoea, current smoker
• DASI 4 METS

Issues

• Very keen for the procedure to proceed as symptoms limiting quality of life
• Difficult to ascertain reasons for poor glycaemic control
• Patient unaware of potential implications to health, particularly in the perioperative period
• Distance patient, postponement on the day of surgery would be a major inconvenience to the patient
• Unable to contact proceduralist, junior team members contacted and happy to continue

Discussion

• Endocrine and GP review organised but limited time
• Should we try and admit the patient the night before and commence an insulin infusion?
• Risk of no bed being available then procedure could be postponed
• Consensus that procedure is high risk for postoperative infection and should be postponed

Plan

• Operating Surgeon eventually contacted – happy to defer until glycaemic control improved.
• Expediate endocrine and GP reviews

PIG Meeting Notes

PIG Notes 8th April 2021

Cases

• Colon cancer and angina
• Cardiac Anaesthetist for Ganglion Removal
• CREST Syndrome for Colonoscopy
• Right Frontal Insertion of Rickman Reservoir
• Thoracoabdominal aneurysm repair and CSF drain
• Toe Amputation Vs Hiatus Hernia Repair