Category PIG Meeting Cases

Ivor-Lewis Oesophagectomy with Ischaemic Heart Disease

garychleung

PIG Meeting: 18th February 2021

69 year old man with Oesophageal cancer

Background

  • Routine preoperative CPET testing revealed ischaemic ECG changes, suspicious of LM disease

Issues

  • Asymptomatic. Noted to have an excellent exercise tolerance on DASI.
  • Exercised to 90% of predicted HR with AT of 15.6ml/kg/min and VE/VCO2 24.6. This represents excellent exercise capacity and would usually indicate patient is fit to proceed to major surgery.
  • Discussed with Dr Collins at the Perioperative Cardiology meeting. Concern re left main coronary artery disease – recommended angiogram
  • Coronary angiogram which revealed mid-eccentric LAD stenosis of 60-70% with normal LVEF
  • No coronary intervention required. Plan to proceed with surgery

Discussion

  • Value of CPET in this instance. Was it a useful test?
  • Discussion centered around the finding of a pathology that didn’t require any intervention.
  • Patient didn’t perform Prehab due to possibility of coronary disease. Was he disadvantaged?
  • Should we be performing CPET in all patients for major surgery or just in those who are clinically borderline candidates?
  • Consensus that there is sufficient evidence for CPET testing perioperatively for major surgery. This patient performed well despite recent completion of NAC and that provides treating team with good prognostic information perioperatively.
  • No delays to surgery and prehabilitation unlikely to improve fitness further as already excellent.

Plan

Ameloblastoma

garychleung

PIG Meeting: 18th February 2021

86 year old man, consult for Partial Maxillectomy and free flap

Background

  • Chronic lesion in left maxillary sinus with one episode of bleeding last year.
  • CT showed aggressive infiltration in posterior maxilla and pterygoid plates.

Issues

  • Multiple co-morbidities but no active concerns at present and has good QoL at home with wife and supportive family

Discussion

  • Perioperative Risk scoring – SORT score and NSQIP both showed significant risk of mortality, but numbers were discordant 11 vs 3.3%. Why was this?
  • Discussion around the nuances of each risk calculator; SORT score comparatively calculates less risk for cancer patients whereas NSQIP can appear to overestimate perioperative risk, not the case in this instance.
  • The consensus was that the morbidity outcomes were very significant for this patient regardless of mortality outcomes.
  • Patient and family very concerned with preserving QoL and understanding of the limitations of his age and co-morbidities.

Plan

  • Discussion with surgical team regarding other, less invasive surgical options or radiotherapy.
  • Surgical MDT is next week. Further discussion required before proceeding to surgery.

Mitraclip

garychleung

PIG Meeting: 18th February 2021

First Mitraclip procedure at JHH performed successfully this week!

Background

  • 86 year old man
  • Severe MR, 4 recent admissions to hospital with worsening CCF despite optimal medical therapy .
  • Arial fibrillation, on Apixaban
  • Not a suitable candidate for cardiac surgery given significant frailty and co-morbidities.

Issues

  • New procedure, some uncertainty around what to expect in the perioperative period regarding vasopressor and/or inotrope requirements. Possibly some requirement for inotrope as cardiac status changing from mitral regurgitation to relative mitral stenosis.
  • Anticoagulation ceased for 24 hours preoperatively in consultation with cardiologist
  • Venous access using femoral vein and an atrial septal puncture, theoretically lower bleeding risk than other angiographic procedures via femoral artery
  • Backup plan discussed if open cardiac intervention required – this may include valve dysfunction or embolization of device

Discussion

  • Further mitral clip procedures planned in future. Note that there have been patients that have presented to perioperative clinic for other surgeries who are awaiting Mitraclip procedure. Patients should be on optimal medical therapy for heart failure prior to being considered for Mitraclip procedure.
  • Literature shows similar improvement in symptoms and decrease in hospital admissions with mitral clips vs open cardiac surgery. Survival benefit and improved clinical outcomes with mitral clips vs goal-directed medical management (See attached papers CO-APT trial and EVEREST trial).

Plan

  • No specific perioperative interventions required than standard cardiac assessment of valvulopathy patient
  • Case presented to raise awareness of potential patients presenting to pre-operative clinic

PIG Meeting: 11th February 2021

garychleung

PIG Meeting Notes

PIG Notes 11th February 2021

Cases

Severe metabolic shock after open abdominal aortic aneurysm repair

garychleung

PIG Meeting: 11th February 2021

Case details

  • Sestamibi preop (organized by vascular surgeons) – normal EF and nil ischaemia
  • Uneventful procedure, short clamp time
  • EDB functioning well, extubated, transported to ICU, doing well
  • ~3am developed shock + respiratory failure
  • Reintubated, NAd and vasopressin commenced
  • Cause of shock difficult to establish
    • CT showed no bleeding, all vessels perfused, some small areas of gut ischaemia but not thought significant enough to cause the degree of shock
    • Bedside TTE – difficult views but nil obvious cause of severe shock
    • Fluid responsive with lactate dropping from 9 to 5 with fluid resus
  • Surgical team reluctant to take patient to OT for a re-do laparotomy which they believed was likely to be non-diagnostic.
  • Patient eventually taken to OT – ischaemic colon and 2m of small bowel – resected, abdo left open
  • Patient survived with AKI

Discussion

  • Discussion involved consideration of immediate postoperative complications needing surgical complication to be excluded. This case shows the important of looking to the obvious, common causes of shock in a patient after major surgery.
  • Discussion about whether or not a TOE should have been used in this patient while the cause of shock was still unclear. The clinician felt that the limited TTE views obtained were adequate to exclude a cardiac event as a cause of shock, at least while the most likely source (an intra-abdominal complication) was still being investigated.
  • Acknowledged that re-look laparotomies have an accepted false negative rate, in order to avoid missing the opportunity for life-saving intervention.

Cancellation for hypertension

garychleung

PIG Meeting: 11th February 2021

Case details

  • 1st case: ~66yo woman, distance patient, nil pre-op review, previously diagnosed with HTN, now not medicated (reason unclear). For Bx of vaginal lesion. BP 220/110 + headache, malaise.
  • 2nd case: 92yo lady, for hysteroscopy and D+C for postmenopausal bleeding. Phone consultation from clinic. Similar BP.
  • Surgeons amenable to postponement in both cases.

Discussion

  • Would others have cancelled these patients?
    • Some variability in anaesthetist practices.
    • AAGBI guidelines suggest that if patient’s primary care BP is not known, up to 180mmHg SBP and 110mmHg DBP are acceptable on DOS (See flowchart below and attached paper).
    • The symptoms associated with the severe HTN in the 1st case were felt to be particularly concerning. Patient was reviewed by med reg and started on regular antihypertensives, prior to d/c home.
  • Was this avoidable?
    • Even with in-person consultation this is a difficult issues, with DOS and clinic BPs often falsely elevated due to anxiety and medication changes.

AAGBI recommend not checking preop BP in clinic if documented at acceptable levels from GP (<160/100).

Cancellation for acute shortness of breath

garychleung

PIG Meeting: 11th February 2021

Case details

  • Phone consult in preop clinic
    • History of well controlled, stable asthma
    • Noted to have sore throat – patient encouraged to obtain COVID test (negative)
    • Pt developed URTI, associated with asthma exacerbation. Surgery postponed.
    • Patient health check prior to new surgery date – symptoms resolved, ok to proceed.
    • DOS – patient acknowledges SOBOE (NYHA Class III). A marked decline from resp function pre-URTI. Wheeze in chest? Surgery cancelled by procedural anaesthetist.

Discussion

  • Was this avoidable?
    • This patient was reviewed by phone in clinic, so while her chest was not examined, it seems that it was the URTI which developed after this consultation which led to her asthma deterioration.
    • Correct procedures were followed with a pre-op health check, however it was only with detailed questioning from the procedural anaesthetist that the patient revealed the key info.
  • Would other anaesthetists have cancelled the patient? – Agreed that for elective surgery, with an ongoing respiratory exacerbation postponement is appropriate. Important to exclude other causes of new SOB (e.g. CCF) if expected resolution doesn’t occur.
  • Have there been an increase in DOS cancellations with our move to phone consultations during COVID? – No
  • Are we proceeding with surgery in patients whom we recognize are un-optimised to avoid DOS cancellations? – Not as per the meeting attendees.

Laparoscopic radical nephrectomy with unoptimised ischaemic heart disease

garychleung

PIG Meeting: 11th February 2021

57yo male with renal cancer for radical nephrectomy.

Background:

  • BMI high ++
  • T2DM
  • Dyslipidaemia
  • HTN

Issues

  • ? Ischaemic heart disease
    • Exertional chest pain
    • GP arranged a stress ECG – positive
    • Saw cardiologist –  stress ECG again positive and the patient experienced chest pain, but stress echo negative for ischaemia. Discharged from cardiologist’s care.
    • CTCA arranged which showed severe RCA vessel narrowing.
    • Reviewed at cardiology-anaesthetics meeting – suggested angiogram and likely PCI.
    • Discussed with surgeon –
      • Will operate on aspirin but not on clopidogrel
      • Based on tumour imaging suggesting nil capsular invasion, ok to delay surgery 3/12 to enable cardiac stenting and short duration DAPT.

Discussion

  • Why did this patient have so many non-invasive cardiac tests?
    • Usually patients have invasive cardiac testing (angiography) if one non-invasive test is positive, especially in the setting of symptoms.
    • Perhaps due to GP’s strong suspicion that there was underlying IHD.
  • What are the current guidelines around duration of DAPT after PCI?
    • Case-by-case basis, with multiple factors influencing decision (essentially bleeding v. Stent thrombosis)
      • Patient – diabetes, ACS, age, LV function
      • Stent – calibre, overlaps, branching, length, DES v. BMS
    • AHA guidelines recommend 3 months of dual antiplatelet therapy post drug-eluting stent (See diagram below).
    • Recent database evidence from Denmark suggests risk of MI and cardiac death after DES is elevated only with surgery within the first month after stent placement (See attached paper).
    • All such cases require consultation with the treating cardiologist and surgeon to reach a compromise.

Fructosamine in the perioperative period

garychleung

PIG Meeting: 11th February 2021

Follow on from recent PIG patient, booked for TKR, with poorly controlled diabetes among her many comorbidities. Qualification sought from surgeons about their accepted preop HbA1c. Surgical team advised that max 7.5% accepted but that fructosamine level may be used if patient is borderline, as a means to either justify or refuse surgery.

Discussion

  • What is fructosamine?
    • Refers to glycosylation of plasma proteins, predominantly albumin.
    • Higher plasma glucose levels lead to increased glycosylation (similar to glycosylation of Hb)
  • What is its significance?
    • Plasma proteins have shorter t1/2 than Hb, so it fructosamine level reflects glucose control over the previous 2-3wks.
  • What does it mean in context of surgery?
    • Limited evidence for HbA1c correlating with postoperative outcomes (and no evidence for 7.5% v. 8.5% cutoff)
    • Evidence exists for improved outcomes with better glucose control in the more immediate perioperative period.
    • 2019 paper showing correlation between higher preop fructosamine levels and higher rates of periprosthetic joint infection, reoperation and readmission. Although significant potential issues about the validity of this trial
  • Should we be targeting fructosamine instead of HbA1c?
    • May be a target in the future but this would require a review of evidence and agreement between the orthopaedic surgeons, periop service and endocrinology service.
  • What are the details of the test itself?
    • At JHH 10-30 of these processed daily
    • Run 24h a day, with a turnaround time similar to a UEC.
    • Cost – Awaiting advice from pathology revenue department.