65yo male with a thoracic aortic 5.5cm descending aneurysm, endograft (fenestration for left subclavian) with rapid pacing.
- Recent ex-smoker
- Non-labelled thrombophilia (DVT/PE’s 70s) on Xarelto
- DASI 5.1
- Wegener’s recent diagnosis:
- 3/12 history of increasing SOB (unable to complete 1 FOS) + palpitations
- Cardiologist proceeded straight to angiogram due to high pre-test probability of obstructive CAD. Angiogram was ~ normal.
- Respiratory review – diagnosed with Wegener’s granulomatosis
- High dose prednisone improved his CXR changes/spirometry and an associated pancolitis.
- ? Fit for surgery
- Immunologist says pt will never be cured from his vasculitis.
- Aim is to wean off high dose prednisone
- Graft may not be ideal with vasculitis.
- Ongoing immunotherapy
- Revisit in 3 months
45yo female for whole body MRI. Previously attempted with oral anxiolysis due to severe claustrophobia but patient became extremely distressed. Repeat attempt booked today under GA.
- ? Myositis
- Subjective muscle weakness since 18mths
- CK 1500, weakly positive myositis antibodies
- Rheumatologist advises only avenue for diagnosis is whole body MRI
- Chest pains – CTPA negative, costochondritis, referred to cardiologist, CT heart (? CTCA) pending.
- BMI 55
- Ex-tolerance 50m
- PCOS (metformin)
- Likely severe OSA (declined testing due to claustrophobia)
- Should procedure occur today?
- Not reviewed in periop clinic as these bookings do not come through the surgical services pathway
- Non-urgent procedure given lack of progression of symptoms over 18mth time frame.
- Rheumatologist and patient both pushing for MRI today.
- What would we optimise if review had occurred?
- OSA won’t affect this procedure (no incision, no opioids afterwards), patient declining testing and CPAP.
- Significant preoperative weight loss unlikely
- Ideal to know the outcome/concerns of the cardiologist involved, documentation missing.
- Attempt to contact cardiologist by phone. If they do not feel that severe IHD or other cardiac issue is likely, then should proceed with MRI under GA.
If cardiologist not able to be contacted and anaesthetist feels the low exercise tolerance and chest pain have a high pre-test probability for perioperative M&M, reasonable to postpone an elective procedure for periop review.
Male 77yo with a known bladder cancer for cystoscopy and diathermy.
- COPD 48% FEV1
- Smoker – 120PYH
- Post-polio syndrome with chronic pain
- Chronic lower back pain
- Opioid tolerant ++ (160mg BD MS Contin, 10mg QID endone)
- Incidental finding of LUL lesion (SCC ON BX)
- May be a candidate for curative surgery
- Should surgery proceed?
- Similar level of morbidity to many of our urological patients
- Minimally invasive procedure
- Potential for significant morbidity prevention; diathermy of a small bladder cancer recurrence now will prevent large tumour (requiring larger procedure) or anaemia from bleeding at a later date
- Low analgesia requirements so patient’s existing opioid tolerance not a huge concern
- Opportunities for optimisation looking towards possible thoracic surgery
- Proceed with urology procedure
- Contact GP/patient about optimisation opportunities
86yo male, for possible (open) fenestrated cuff repair to previous aortic stent graft due to endoleak.
- AMI ’95, medical therapy since.
- Sestamibi (organised by vascular surgeons) shows large, fixed defect and no reversible ischaemia. EF 30-35%.
- DCM due to above (EF 35%).
- TIA 5yrs ago, no residual
- EVAR 2018
- RCRI 3-4 = elevated risk
- DASI 7.5METS, chops wood!
- Should surgery proceed?
- Appeared well at F2F review and DASI very reassuring
- Advanced age with multiple significant comorbidities – ABS data suggests 6yr life expectancy for the average 86yo Australian male
- Is his heart failure optimised?
- Discussed at cardiology meeting:
- Biventricular pacing to improve EF? – unlikely to improve cardiac function in this patient. Indicated with wider QRS which is indicative of desynchrony.
- Suggested addition of loop diuretic or spironolactone (doesn’t clinical appear overloaded)
- Cardiologist opinion – patient has significant IHD with a substantial effect on his cardiac function. Recommended to reconsider surgery given high risk for poor perioperative outcome.
- For further discussion with surgeon about risks/benefits from their perspective.
70+ yo male with previous meningioma. Now for cranioplasty for cosmetic purposes.
- Meningioma – excised, followed by craniectomy for infected bone flap.
- Metastatic bowel cancer (liver met)
- NSTEMI Feb ’21, precipitated by reduced exercise tolerance and angina.
- On apixaban and aspirin (for AF and PCI)
- Should surgery proceed?
- Patient feels this will significantly add to his QoL
- Plan pending for his metastatic bowel cancer, potential candidate for a partial liver resection in the future.
- Oncologist suggests 2yr survival from the bowel cancer is reasonable (supporting decision for cranioplasty) and that this surgery won’t negatively affect his liver metastasis prognosis.
- Craniectomy can be therapeutic in the setting of previous decompressive craniectomy, speeding neurocognitive recovery. Not relevant to this patient.
- How to manage antiplatelet and anticoagulant agents, and timing since PCI for non-urgent surgery
- NSx happy to perform procedure on aspirin
- Discussed at anaesthetics-cardiology MDT – waiting until 12mth post PCI will not reduce this patient’s risk of MACE, especially if aspirin is able to continue perioperatively
- Bridging not indicated. CHADS2 score = moderate risk. Evidence continues to support no bridging in this patient group due to increased bleeding risk without prevention of thromboembolic events.
- Proceed to OT.
- Continue aspirin.
- Withhold anticoagulant. No bridging therapy.
46-year-old for consideration of laparoscopic cholecystectomy
- Chronic pain – ankle injury at work. In Cam Boot since November 2021. Awaiting chronic pain specialist input
- Complex PTSD
- Difficult social circumstances/isolation
- HFREF – New diagnosis in January 2022
- Dilated cardiomyopathy, EF 37%. Moderate functional MR
- Admission with decompensated heart failure post-covid infection.
- Alcohol-related, drinking 2 litres of wine per day
- Commenced on optimal medical management: bisoprolol, Entresto (Sacubitril/Valsartan), spironolactone and furosemide. See figure below.
- Symptoms stable – no orthopnoea/PND. Mild pitting ankle oedema.
Pharmacological management of HFrEF
MRA – mineralocorticoid antagonist. ARNI – angiotensin-receptor neprilysin inhibitor
- Cholelithiasis – recurrent biliary colic. No admissions or cholecystitis.
- Alcohol abuse – abstinent since January but currently struggling with this.
- Cardiology meeting discussion with repeat echocardiogram
- Some improvement in echo but not as much as expected 3 months post-event.
- LV now mildly dilated, LVSF unchanged/slightly improved. MR mild.
- Outpatient review with cardiologist required preoperatively
- Ensure euvolemia and careful cardiac monitoring perioperatively
- NT proBNP = 298. Borderline, suggestive of increased perioperative risk and therefore aids in decision-making with regards to perioperative monitoring and level of postoperative care.
- Alcohol abuse
- Multiple significant contributors
- Discussed options for support, patient keen to engage.
- Await cardiologist review
- Aim for surgery with 3 months.
43-year-old lady for consideration of laparoscopy for investigation of endometriosis, pelvic pain, and menorrhagia
- Type 1 DM, good glycaemic control
- STEMI in 2020. Post-partum.
- LAD stenosis 90%. PCI to LAD,
- HFrEF with global hypokinesis
- Admission post PCI with APO but now stable on medical therapy
- Excellent exercise tolerance
- Regular cardiologist review
- confirmed on Muscle biopsy
- Previous trigger-free GA without issue
Management of Insulin Pump Perioperatively
- Current guidelines recommend liaison with endocrinologist perioperatively
- Endocrinologist letter:
- Patient can adjust pump during the fasting period.
- Preoperatively check BSL and Ketones. If BSL > 15mmol/L and/or ketones raised on arrival to hospital, postpone surgery and call the endocrinology registrar
- Cease insulin pump pre-induction and commence IV insulin-dextrose infusion
- Insulin infusion with IV dextrose to continue until she has tolerated one good meal and can self-manage pump.
- Continuous glucose monitor can be used to monitor BSL in conjunction with regular capillary measurements
- IV fluid administration may affect accuracy as can alter the composition of interstitial fluid
- Manual finger prick glucometer should be done regularly.
- Perioperative target = 6-12mmol/L
- Evidence to suggest monitoring system may be affected by diathermy/EMI. (Note effects are uncertain, likely a warranty issue).
- Therefore, best practice to monitor capillary glucose regularly even for shorter procedures
- Proceed to surgery
- First on list, trigger-free anaesthesia
- Management of insulin pump and continuous glucose monitor as per endocrine advice
78-year-old man for EVAR, 55mm AAA
- Nursing home resident
- Lung nodule – mild uptake on PET, uncertain aetiology. Under surveillance by respiratory physician. Not a candidate for surgery
- COPD. Ongoing smoker. 90PY. FEV1/FVC = 41%
- Hypertension and high cholesterol
- DHS – hip fracture, 2020. GA
- Incarcerated hernia repair under GA 2021
- AAA – Incidental finding, Infra-renal. 5% annual rupture rate
- Wheelchair-bound, Severe OA both hips
- Assistance with all ADL’s
- CVD, Cognitive impairment – mini cog 3
Clinic consultation with patient and son:
- Patient is keen to leave nursing home but has a reasonable quality of life which he enjoys.
- High risk for further cognitive decline
- Risk of mortality is more than risk of rupture – both theoretical
- Clinic anaesthetist advised against proceeding; benefits of procedure greatly outweigh potential long-term risks. Patient uncertain regarding this decision. Capacity to consent has not been formally examined.
- NSQIP surgical risk calculator showed a 24% risk of serious complication and a 12.4% risk of death.
Benefits vs Risks
- Consensus agreement with clinic anaesthetist.
- Life expectancy is limited at 78 years old with significant co-morbidities
- Patient is at risk of declining quality of life which he currently values
Where to from here?
- Should this conversation be continued over the phone or a repeat face to face consultation?
- Decision-making capacity uncertain – formal assessment needed.
- GP could consider geriatrician referral
- Daughter is NOK but was not in attendance. No POA/substitute decision maker.
- Important to note that declining this procedure based on perioperative risk would not preclude him from further surgeries e.g., hip-fracture surgery
- Not for EVAR, letter to referring surgeon recommending conservative therapy
- Further meeting with family and clear documentation in notes required
GP to assist patient and family with advanced care planning
70-year-old for laparoscopic Bilateral Salpingo-Oophorectomy and ovarian cystectomy
- CKD – stage 3
- Complex ovarian mass
- BMI 41
- Severe COPD
- FEV1=0.6 (31%), FVC=1.45 (52%)
- Has preventer but doesn’t use, Ventolin a few times per week
- Oxygen saturations 95% at clinic
- No formal diagnosis/respiratory physician review
- Decreased functional capacity, 4 MET’s
- Pulmonary hypertension
- Previous admission for fluid overload/HFpEF in 2016
- In anaesthetic bay – described exertional angina and orthopnoea
- uncertain history of NSTEMI.
- Cardiologist review previously but hasn’t been seen for a while.
- Discussed with surgeon on day, cancer unlikely. Agreement to postpone for investigation and risk-stratification
- Short notice patients in clinic due to covid cancellations and recovery
- Imperative to discuss with proceduralist if any concerns
- Patient was on gynae-oncology list, but not a cancer patient
- Review process for Respiratory Rapid Access Clinic currently underway by Dr Papeix. Recent meeting with respiratory physician revealed:
- Role for some patients to have a RAC review perioperatively
- Minimal optimization achievable in setting of stable COPD. Approximately 20% would have eosinophilic picture and would benefit from inhaled steroids
- Majority already on LAMA/LABA
- Inhaled steroids overused in community and main function is to decrease frequency of exacerbations
- Minimal role for inhaled steroids in reduction of perioperative risk
- Asthma – Asthma control questionnaire. Role for management of asthma perioperatively. Oral steroids take weeks to improve control and for those that qualify for leukotriene-receptor antagonists, months
- Cystic Fibrosis – regular review by specialist but should be seen preoperatively
- Interstitial lung disease – some therapies which can impact systemic inflammatory process. Can take weeks to see improvements
- Role for respiratory review in undifferentiated dyspnoea where cardiac cause has been excluded
- Discussed at cardiology meeting – referral to cardiologist in local area for review and likely stress cardiac imaging
- Postpone for 3 months
- Await cardiologist and respiratory review
- Follow-up in perioperative clinic