? Ovarian cancer v. Decompensated liver failure

57-year-old female with an ovarian mass for Investigation.

Background 

  • Liver disease
    • Long history of untreated HCV
    • Now diagnosed with Childs Pugh B liver cirrhosis – albumin 20, bilirubin 64, platelets 57.
    • Recent admission with decompensation – severe hydrothorax treated with diuretics.
    • Antivirals recently commenced but not with curative intent.
    • Letters suggest gastro teams and gynae team all aware of both issues.
  • Ovarian mass
    • Incidental finding although some abdominal discomfort
    • 7.7cm2 
    • Ca125 274 (could be elevated due to liver disease)
  • Asthma
  • PAF 

Discussion 

Should surgery proceed?

  • Phone call to gastroenterology team: 
    • High risk of haemorrhage (very difficult to control) with any abdominal surgery, especially laparoscopic, due to portal hypertension.
    • High risk of postoperative decompensation, encephalopathy, infection, and wound breakdown.
    • Patient requires urgent variceal banding, but this will worsen portal hypertension.
    • Delay of 2/12 to enable gastroscopy, ongoing antiviral treatment, anti-portal HTN treatment, repeat imaging, and possible mild improvement.
  • General opinion at the meeting was that the real risks highlighted by the gastroenterologist superseded the theoretical risks of a delayed diagnosis of a possible ovarian cancer (patient unlikely to be a candidate for radical curative surgery or chemotherapy). See attached summary article.
  • TIPS (or similar procedure) may be an option to offload portal hypertension prior to consideration for gynae surgery – for further discussion after 2/12 delay.

Open v. Endovascular Aortic Recon

62-year-old indigenous lady with complete occlusion of the distal aorta. 

Background

  • PVD
    • Thrombosed distal abdominal aorta and occlusive iliac artery disease
    • Claudication and lower limb ischaemic neuropathy
    • 50m on flat with 4WW -> rest
  • COPD – moderate, NYHA class III, nocturnal cough, ceased smoking 1/12 ago, symptoms improving.
  • NIDDM – good control
  • PAF/flutter – on rivaroxaban and beta blocker
  • HTN and Dyslipidaemia
  • Chronic back pain
  • Lifelong high WCC, up to 23, cause unknown
  • Obesity

Issues

  • Incidental finding of adrenal lesion
    • Seen on CTPA done in context of chest pain and rapid AF (self-resolved). CTPA negative
    • CT images suggest consistent with adrenal adenoma

Discussion

Adrenal lesion

  • Common pathology – prevalence of 7% of people over 70yo (as per BMJ best practice)
  • Investigate – Before non-emergency surgery, yes. Especially this surgery with consequent physiologic derangement.
  • Need to exclude Cushing’s, phaeochromocytoma, and primary hyperaldosteronism
  • Endocrine team requested – Plasma metanephrine and catecholamines, a dexamethasone suppression test, renin:aldosterone ratio, and DHEAS

WCC 

  • Haematology AT suggests could be due to obesity and smoking.
  • Further pathology tests requested to exclude myeloproliferative disorder although thought unlikely. 

Open v. Endovascular procedure

  • For open procedure: SORT 2.59% risk of death (not adjusted for clinician assessment), ARISCAT 13.3% (moderate) risk of POPC, Gupta postop pneumonia 7.3% NSQIP risk of serious complications 16% v. 23% with open procedure.
  • Proceed with open procedure if desired for surgical reasons, given the above risk indices.

Splenectomy for spherocytosis, URTI

25 year old patient for laparoscopic cholecystectomy and splenectomy due to hereditary spherocytosis.

Background

  • Hereditary spherocytosis
    • Pigment gallstones and biliary colic
    • Symptomatic splenomegaly
    • Hb drop from 132 to 107 over last 3 weeks
    • Recurrent severe haemolytic crises – Admission this year with nil precipitant, Hb drop to 40g/L
    • Pre-splenectomy vaccinations up to date
  • Anti-E antibodies (due to recurrent blood transfusion)
  • Smoker​

Issues:

  • Current URTI
    • COVID negative
    • Improving last 2 days, almost normal

Discussion

  • ​What is hereditary spherocytosis?
    • Autosomal dominant, abnormality of red cell membrane structural proteins
    • Classically diagnosed in children with haemolytic anaemia after Parvovirus infection, but may be asymptomatic
    • Variable severity.
    • Precipitated by infection
    • Splenic red cells sequestered in spleen, shortening T1/2 to as little as 10d.
    • Anaemia, splenomegaly, jaundice, increased reticulocyte count and spherocytes on peripheral blood smear.
    • Gallstones common, occurring in 50% of HS patients by 50yo. 
    • Treated symptomatically, with folic acid, transfusions, vaccinations (same as for splenectomy), cholecystectomy and splenectomy, as needed. 
    • Risk of overwhelming post-splenectomy infection (OPSI). Pneumococcal vaccination required preop. Prophylactic antibiotics used for at least 3 years, lifelong in some cases. Patients always carry emergency antibiotics with them, due to risk of rapid progression of sepsis. 
    • Splenectomy also carries a long-term thrombosis risk.
    • Spherocytes persist in the blood after splenectomy, but their lifespan is normalised. 
  • Should surgery proceed given current URTI?
    • Frequent URTIs in the community at present, may cause repeated delays to surgery.
    • ARISCAT scoring (assuming conversion to open abdominal procedure) suggests proceeding within 1 month of URTI in this​ patient would be associated with high risk (~44%) risk of POPC, dropping to moderate risk (~13%) thereafter.
    • Severity of haemolytic crisis this year is motivation to proceed.

Plan:

  • Proceed with surgery, as discussed with the treating surgeon.
  • Phone call to procedural anaesthetist

Frail patient for TKR

80-year-old female for TKR. Previously postponed due to lower limb infections. 

Dermatologist input – legs as good as can be.

Background

  • Widespread OA with severe kyphoscoliosis
  • Mild Asthma, distant ex-smoker, FEV1 70%, FVC 85%, ratio 74%
  • Hiatus hernia
  • Low ex tolerance <4 METS
  • CFS 6, always requires 4WW and significant assistance with ADLs
  • TTE – mild PHTN, EF=61%
  • Iron deficiency anaemia

Issues

  • Iron deficiency anaemia
  • Frailty, concerns about recovery.

Discussion

IDA

  • Additional investigations required?
    • Longstanding since 3yrs.
    • GP has been treating with iron but nil additional investigations
    • Likely due to inadequate intake, but GI malignancy should be excluded (unlikely but endoscopies usually part of the routine workup)
  • Stress myocardial imaging – low exercise tolerance but nil active cardiac conditions/symptoms and RCRI class 1, so not indicated as per the ACC/AHA guidance.
  • Should surgery proceed?
    • Extensive risk discussions with patient and family members. Appropriate to proceed as this is in line with the patient’s values and understanding.

Plan

  • Speak with GP regarding Fe deficiency – are they satisfied that this represents poor intake rather than a more sinister cause requiring investigation. If so, proceed with further Fe infusion and surgery.
    • Update – GP only took over care ~6/12 previously. Feels that further investigation is warranted. 
    • Postpone surgery while awaiting above.

Multiple comorbidities for THR

61-year-old male for THR

Background

  • BMI 56
  • OSA – severe AHI 86, can’t tolerate CPAP
  • Chronic back pain
  • Hiatus hernia

Issues

  • OSA 
    • HCO3 normal, unlikely to have obesity hypoventilation syndrome
    • SpO2 on RA 97%
    • Patient cannot tolerate mask
    • Limited scope for optimisation apart from weight loss
  • BMI 56
    • Likelihood of preoperative weight-loss small.
    • Evidence for weight loss strategies points to gastro-reductive surgery, but extremely limited public availability (especially with absence of metabolic syndrome) and expensive in the private sector.
    • There is merit at face value for preoperative weight loss, but no clear evidence to suggest improved outcomes.
    • Unusual that patient was offered surgery at this BMI.  See table below, obesity and smoking only co-morbidities with RCT evidence to support increased perioperative risk.
  • SOBOE
    • Reviewed by cardiologist. Sestamibi normal. TTE showed diastolic dysfunction (diuretics commenced)
    • SOB thought to be multifactorial – diastolic dysfunction, obesity, deconditioning. 
    • Nil further cardiac investigations thought necessary by cardiologist
Table

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Plan

  • Proceed with surgery
  • Encourage compliance, where possible, with CPAP
  • ICU level 3
  • Neuraxial technique and minimal sedation recommended.

Obesity hypoventilation and laminectomy

64-year-old male for L4 laminectomy. Cancelled in anaesthetic bay 3/12 ago with SpO2 85% and HCO3 37

Background

  • Lower limb neurology due to spinal canal stenosis
  • OSA/OHS – New diagnosis after last attempted surgery
  • Now on BiPAP (IPAP 18, EPAP 10, backup RR 10), daytime SpO2 improved to ~90%, ESS reduced
  • Obesity BMI 44
  • Distant ex-smoker, nil COPD
  • Mild asthma, distant puffer use.
  • HTN
  • AMI 2014, medical mx, now discharged from cardiologist care

Issues

  • unoptimised OHS?
  • ABG in clinic – PaCO2 55, PaO2 63, HCO3 30

Discussion

  • Should procedure be postponed?
    • Significant lower limb neurology, neurogenic claudication, and numbness
  • Possible optimisation
    • May require O2 addition to BiPAP to further stimulate respiratory drive (although recent overnight oximetry shows SpO2 ~90% on average). 
    • Consultation and further adjustment of BiPAP may be possible while inpatient post-operatively
    • TTE to assess for cor-pulmonale due to OHS (difficult to assess due to limited mobility due to lower limb neurology, obesity, and chronic lower limb oedema).

Plan

  • TTE
  • Proceed with OT
  • Respiratory AT agrees with plan to proceed and asked to be notified on admission so that they can provide input postop.

EVAR with COPD

83-year-old lady admitted to hospital with abdominal pain. Incidental finding of 6.4cm infra-renal AAA

Background

  • Severe COPD, recently commenced on home oxygen
  • Recent admission with infective exacerbation 
  • Type 1 respiratory failure, Room Air PaO2 = 55mmHg
  • Spirometry – FEV1/FVC: 0.99/1.48: 0.67. TLCO 37%
  • HFpEF. 1.5 litre fluid restriction
  • Pulmonary hypertension, moderate
  • Large hiatus hernia with uncontrolled GORD
  • Severe kyphosis

Issues

  • Incidental finding of AAA, suspicion of leak on scan
  • Ongoing abdominal pain
  • Haemodynamics and Haemoglobin stable

Discussion points

Should surgery proceed?

  • Large aneurysm, annual rupture rate around 10%
  • Respiratory physician opinion that survival from COPD is “a few years.”
  • Patient keen for procedure, has supportive family and great-grandchildren nearby
  • Not suitable for an open procedure
  • Patient and family fully aware of risks

Optimisation

  • Echocardiogram? Enable assessment of LV function and Pulmonary hypertension – not likely to change management

Conduct of Anaesthesia

  • Sedation vs GA vs epidural
  • Patient can lie flat without significant dyspnoea, but procedure expected to last around 90 minutes
  • Breath-holds required and can be painful
  • Aspiration a concern with sedation
  • GA may facilitate faster procedure
  • Aim to extubate at end of case
  • Epidural may prove difficult given kyphosis

Disposition ICU bed if GA/any complications

TKR and OSA

76-year-old lady for elective TKR

Background

  • Significant knee pain, impacting QoL
  • COPD, mild. 60 pack year smoking history
  • Ceased smoking to facilitate TKR
  • Peripheral vascular disease, multiple revascularization procedures. On apixaban
  • BMI 46
  • NIDDM. Poor glycaemic control
  • Difficult to obtain accurate history in clinic
  • Some indications of poor medication compliance
  • On ?CPAP for OSA. Advised to bring to hospital.
  • Extensive perioperative work-up, including delay to improve glycaemic control

Issues

  • Presented for TKR. Uneventful intraoperative course.
  • Developed Type 2 respiratory failure in PARU
  • Home machine not functioning due to water ingress, sent to biomed
  • Commenced on NFNP with little effect
  • Reviewed by respiratory CNC in PARU. Patient well known to service
  • Patient has significant OHS and is on home BiPAP (IPAP 17, EPAP 9)
  • Device history revealed recent non-compliance with therapy
  • Respiratory department sourced a replacement machine.
  • Patient stable in recovery on usual BiPAP settings and discharged to ward.

Discussion

Conduct of anaesthesia

  • Spinal with intrathecal morphine 100mcg – consensus opinion that this was the optimal anaesthetic choice as avoided parenteral opioids.
  • Some anaesthetists routinely use 150mcg morphine but would decrease to 100mcg in patients at risk of postoperative respiratory depression
  • Consensus in literature than 100mcg is optimal dose for avoidance of respiratory depression

Could this situation have been avoided?

  • Difficult history, multiple complex comorbidities
  • Patient unaware of differences between CPAP and BiPAP
  • Non-compliant with therapy
  • Respiratory CNC provided extremely valuable input and avoided an unplanned HDU admission

Perioperative management of suspected OSA/OHS

  • Clinic guideline under development, ongoing discussions with respiratory dept
  • Sleep studies are time-consuming and turnaround time from referral to initiation of CPAP is around 6 months
  • No RCT evidence to support reduction in perioperative morbidity and mortality with initiation of CPAP therapy.
  • Observational data would suggest that OSA patients have worse perioperative outcomes and there are benefits to initiating CPAP perioperatively. (Anesth Analg 2015;120:1013–23)
  • Aim is to identify those at highest risk of postoperative pulmonary and cardiac complications
  • OHS – more complex sleep disorder with raised HCO3 and PaCO2. Majority also have OSA. These are patients to identify and treat perioperatively.
  • Perioperative assessment: STOPBANG (>3) then perform ESS. If ESS (>8) – consider referral for sleep studies