PIG Meeting: 8th April 2021

67-year-old lady, consult from gastroenterologist for a colonoscopy

Background

• Positive Faecal-occult blood test
• PET scan shows potential Right-sided lesion

Issues

• CREST syndrome with Moderate pulmonary hypertension (on right-heart catheter)
• NYHA class 4 dyspnoea
• Attends Pulmonary hypertension clinic
• Currently on a phosphodiesterase inhibitor, tried numerous other therapies without success
• Significant co-morbidities including SLE and autoimmune hepatitis with liver cirrhosis (Childs-Pugh B)
• Currently being assessed for home oxygen

Discussion

• Consult letter states that the lesion appears low risk from the PET scan and there is the option to wait and repeat the scan
• Discussion around suitability for surgery in the event of a cancer diagnosis from colonoscopy
• Likely not a surgical candidate but many non-invasive options for cancer symptom-management
• Consensus was that the option for a colonoscopy was available to this patient. Some opinions differed on any further optimisation for this surgery.

Plan

• Multidisciplinary discussion required
• Unclear if the proceduralist feels the colonoscopy is currently indicated or would prefer to wait
• More information required before proceeding

PIG Meeting: 8th April 2021

29-year-old lady for elective ganglion excision from her wrist.

Background

• Netherton syndrome – rare autosomal recessive disorder. Characteristic triad of congenital ichthyosiform erythroderma, a specific hair shaft abnormality termed trichorrhexis invaginata (“bamboo hair”), and an atopic diathesis.
• 2 syncopal episodes a few years ago thought to be due to acquired long QT
• Regular cardiology review with recent normal echo and holter.
• No current evidence of long QT, normal ECG at clinic

Issues

• Patient’s mother is requesting cardiac anaesthetist for procedure as per previous cardiologist
• Anaesthetist called new Cardiologist with mother in room, advised she does NOT need to have a cardiac anaesthetist
• Patient’s mother became distressed and left the consultation after extensive discussion that a cardiac anaesthetist wasn’t required for this procedure. She stated that she no longer wanted to proceed with surgery.

Discussion

• Difficult situation to navigate
• Anaesthetic consultant and the patient’s current cardiologist were both involved in the discussions
• The benefits of regional anaesthesia in peripheral surgery were discussed. This was unfortunately declined due to anxiety.
• Techniques to manage the expectations of the patient while still working within acceptable limits of time and clinical resources
• Examples of strategies from pain clinics outlined
• Elective procedure, option to delay surgery and allow family time to consider options
• Complex social and medical needs of family were recognised as significant stressors

Plan

• Follow-up nursing phone call with family revealed that patient has decided to proceed with surgery as planned
• Procedural anaesthetist informed of events

PIG Meeting: 8th April 2021

Referral letter from a general surgeon requesting an urgent perioperative consult for a 63-year-old man with ascending colon cancer.

Daily angina and history of PCI sometime in the last 10 years

Background

• PCI for coronary artery disease in last 10 years
• No regular cardiology follow-up
• No anti-platelet therapy and never been on DAPT
• Daily exertional angina after walking 20-30 metres and after meals
• IDDM
• Morbid obesity

Issues

• Urgent surgery
• Consult letter is concerning that patient is high risk and not optimally managed
• More information is required in order quantify perioperative risk

Discussion

• Patient should be referred for stress imaging
• Discussion around different modalities of stress imaging. Little evidence to suggest superiority, both nuclear imaging and stress echo have high NPV for post op cardiac events.
• Stress echo investigation of choice by cardiologists but not easy to obtain in our district, especially in an urgent setting
• CTCA discussed, non-invasive test, better predictive value in younger people with decreased calcium load
• CTA vision study showed that CTCA over-estimated risk of MACE compared with RCRI. (paper attached)
• Discussion around benefits vs risks of PCI in the setting of urgent surgery.
• May not be possible to delay surgery for 3- 6 months if coronary intervention required
• Newer DES require shorter duration of DAPT
• Need to consider that PCI may not confer a clinical benefit unless a LAD lesion with large areas of myocardium affected

Plan

• Urgent perioperative consult
• Sestamibi and resting echocardiogram
• Referral to rapid access cardiology clinic already underway from surgical team
• Can also be discussed at weekly cardiology meeting

PIG Meeting Notes

PIG Notes 1st April 2021

Cases

• Severe asthma and forehead SCC for free flap surgery
• Poor diabetes control prior to Whipples
• Lap chole and clozapine
• Lap chole and severe COPD
• Review of day-of-surgery cancellation – thyroidectomy

PIG Meeting: 1st April 2021

79yo lady

Background

• Goitre
  • Previous hyperthyroidism, treated with radioactive iodine, euthyroid since
  • Investigated for hot flushes and sweating, multi nodular goitre found on CT, 5mm retrosternal component
  • Surgical review – thyroid barely palpable, minimal symptoms, booked for thyroidectomy

• Day of surgery:
  • ACE-i withheld, SBP 220-250 with nil apparent anxiety
  • ECG normal, patient asymptomatic
  • Nil thyroid imaging since 2019, TFTs last checked in 2015
  • Surgery cancelled

Issues

• Is surgery appropriate in this patient?
  • A respectful discussion with the surgeon can occur in this context, to explore the anaesthetist’s concerns – minimally symptomatic thyroid disease in elderly patient
  • Not uncommon for patients to be booked well in advance of surgery due to long wait-lists. Repeat surgical reviews (in the absence of new or worsening issues) would add substantial burden to the system.
• Could this outcome have been avoided with a face-to-face review?
  • Consider testing TSH 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 (see attached DRAFT pre-operative pathology testing guidelines)
  • BP checks in clinic are controversial, with AAGBI guidelines suggesting that values obtained in the community are more appropriate, however a F2F review would have prompted a discussion with the GP if similar values to this were obtained.
  • We are reviewing our practice in the Preoperative clinic to determine how best to capture BP data for patients having phone consultations.

• BP guidelines?
  • AAGBI guidelines suggest community based BP readings of <160 SBP and <100 DBP should be achieved before elective surgery, while < 180 SBP and <100 DBP are acceptable in clinic or on day of surgery if prior BP readings are unknown.

PIG Meeting: 1st April 2021

79yo male for lap chole due to recurrent choledocholithiasis. Previously cancelled due to lack of theatre time. Spirometry performed on day of surgery (at clinic doctor’s request) but not followed up.

Background:

• HTN
• PVD
• COPD
  • 200m on flat, 1 FOS
  • Community acquired pneumonia 2020
  • Patient feels he’s at his baseline, nil exacerbations since 4-5/12
  • On Spiriva and salbutamol
  • FEV 1 0.62 (30%)

Discussion:

• Indications for spirometry?
  • Surgery type – thoracic surgery, major open abdo
  • Patient factors: 
    • COPD +  intermediate or major surgeries
    • Smoker (>20 years) having intermediate or major surgeries.
    • Uncontrolled asthma.
    • Neuromuscular disorders e.g. M.N.D, Myasthenias)
    • Unexplained shortness of breath.
    • Patients having Consultations for ‘Suitability for Surgery’.
    • At discretion/ request of Anaesthetist rostered in clinic or Procedural Anaesthetist

• What are the risks? Should surgery proceed?
  • ARISCAT, GUPTA (HAP), GUPTA (resp failure) scoring systems all suggests this man’s risk of respiratory complications is low given the laparoscopic nature of surgery.
  • Without surgery he may experience critical illness due to recurrent stones

Plan:

• Proceed with OT
• Notify the procedural anaesthetist

PIG Meeting: 1st April 2021

67yo female for lap chole due to recurrent obstructive jaundice and cholangitis, with one episode causing severe septic shock requiring ICU for vasopressors. Surgery cancelled twice already due to resp status.

Background:

• Schizophrenia
• Dyslipidaemia
• COPD
  • Active, heavy smoker
  • 2 exacerbations this year
  • SpO2 88-93% on RA
  • During exacerbation, FEV1 0.63 33% predicted (previously 1.1L, 50%)
  • Feels she has now returned to her baseline
• Impaired glucose tolerance
• BMI 37
• Neurocognitive disorder – on donepezil
• Hypothyroid – treated
• Lives in group home, guardianship order

Issues

• Should surgery proceed?
  • Surgeons have suggested that if she is predicted to survive 1yr+ (from her other comorbidities) then surgery should proceed
  • High risk of further severe illness related to gallstones
• Can she be optimised?
  • Resp physicians have suggested that nil further optimisation possible while she continues to smoke
  • On appropriate medical therapy

Plan

• Reasonable to proceed with surgery given risk of critical illness without it.
• Tar in cigarettes induces enzymes in the liver, resulting in more rapid clozapine metabolism. Risk of clozapine toxicity with smoking reduction/cessation therefore exercise caution.
• Liaise with clozapine coordinator to ensure all appropriate investigations up to date and to enable clozapine prescription while in hospital (see attached HNE guideline)
• Nil anticipated missed doses of clozapine with this surgery
• Prewarning of the procedural anaesthetist

PIG Meeting: 1st April 2021

66yo male with pancreatic cancer for a Whipples resection

Background

• Recent ex-smoker
• T2DM
• Ex-heavy ETOH (ceased 3/12 ago)

Issues

• Fitness for major surgery
  • CPET showed AT 10.8ml/kg/min and peak VO2 14ml/kg/min, placing him in the moderate risk category
• High HbA1c 11.8%
  • Poor control ++ since dexamethasone used as part of NACRT
  • Known to private diabetician
  • Therapy escalated
  • BSLs improved to 12-14mmol/L

Discussion

• Timing of surgery?
  • Ideally diabetes should be better controlled (as per out guidelines for DM + major surgery) however this is cancer surgery so a risk/benefit analysis must be undertaken
  • After NACRT, a window of opportunity exists, therefore a delay may be appropriate -> discuss with surgeon
  • Control should naturally continue to improve as the effect of the dexamethasone continues to wane
• Diabetes plan
  • Return to private endocrinologist for ongoing care
  • An insulin infusion will almost certainly be part of this man’s care due to insulin usage, major GIT surgery and missed meals.

PIG Meeting: 1st April 2021

74yo male with a positive margin from a previous forehead SCC resection performed under LA. Consultation for suitability for general anaesthesia.

Background

• Severe asthma secondary to ANCA-negative vasculitis(Chrurg Straus disease)
  • FEV1 1.1L (38%), DLCO 53%
  • Gardens, uses mobility scooter outside the home
  • Maximal medical therapy trialled including monoclonal antibody tx. Now on mycophenylate and prednisone.
• OSA on CPAP – non-adherent at present due to forehead lesion interfering with mask
• Obesity with 30kg weight gain over 3yrs in setting of chronic steroids

Discussion

• Are there non-surgical options for his SCC?
  • Concern about asthma exacerbation due to pneumonitis risk with immune cancer therapy.
  • Does not qualify for trials of novel agents due to lack of nodal or distant mets. Qualification on compassionate grounds thought ++ unlikely.
  • Has already trialled radiation therapy – complicated by wound breakdown. Deemed not suitable for further radiotherapy.

• Is his SOB fully accounted for?
  • TTE arranged due to orthopnoea but nil major abnormalities found

• Can he be optimised?
  • Short course high dose steroids unhelpful due to known steroid insensitivity of his asthma.
  • Resp physician feels no further optimisation possible.

• Should surgery proceed? What are the risks?
  • Respiratory physician believes patient likely to live 2+ years with lung disease
  • There is no documented lower limit of mechanical respiratory function at which general anaesthesia is contra-indicated.
  • Wound breakdown felt to be biggest risk given immunosuppression and chronic steroid use for vasculitis
  • NSQIP suggests 2.2% risk of death and 20% risk of morbidity for free flap surgery
  • Low risk of post operative respiratory complications as per ARISCAT scoring but is the unique risk of severe, life threatening intraoperative bronchospasm accounted for in these scoring systems?

Plan:

• Further discussion with surgeons about options for surgery – they report that there will need to be consultation with plastic surgery to minimize risk of wound breakdown. Will likely need 6 hour procedure.
• ICU level 2 booking if surgery does proceed
• Consideration of nasal CPAP
• Return to GP for assistance (e.g. dietician review) for weight loss preop

PIG Meeting: 18th March 2021

With the rollout of COVID vaccine across the community, it is likely that patients presenting to the Preoperative clinic will be potentially having vaccine around time of surgery.

Discussion

• It seems reasonable to plan for patients who will have questions about vaccination in perioperative period.
• There are guidelines around vaccination and surgery. This is usually an issue for paediatric practice (See summary of guidelines below and attached paper).
• There is a recent paper published by the Royal College of Surgeons in the UK to provide guidance for patients having COVID vaccine in the UK (see attached paper).
• The main issue to consider is the vaccine may give some systemic events, such as a fever and chills, within 1-2 days after vaccination, but these resolve soon after. It is reported normally to settle fully within a week. Such a fever is uncommon after dose 1, but occurs in about 15% after dose 2.

Plan

• The following recommendations will be discussed with the surgical services team and be distributed to surgeons, anaesthetists and admissions staff:
  • Essential urgent surgery should take place, irrespective of vaccination status.
  • Non-urgent elective surgery can also take place soon after vaccination. There is some rationale for separating the date of surgery from vaccination by a few days (at most 1 week) so that any symptoms such as fever might be correctly attributed to the consequences of either vaccination or the operation itself.
  • We recommend 5 days between vaccination and elective surgery.
  • Vaccination can take place after surgery as soon as patient has recovered.