83yo male for cystoscopy and stent exchange due to chronic obstruction from uroepithelial carcinoma.
- Uroepithelial carcinoma
- Impaired glucose tolerance
- AF. On apixaban.
- PPM for CHB (99% paced, underlying AF).
- Recent PCI
- Type 2 MI Post-operatively after stent insertion
- Ongoing intermittent chest pain last 6/12
- PCI + rotablation for severe ostial RCA stenosis. 3/52 ago
- For lifelong clopidogrel and apixaban.
- Ureteric stent now 7/12 old, urologists keen ++ to replace
Ideal timing of surgery?
- Discussed with treating cardiologist: happy to proceed 4-6 weeks post-PCI
- Requests to continue clopidogrel perioperatively.
- Discussed with surgeon – happy with plan
Communication in the perioperative clinic
- Much time spent attempting to phone proceduralists and clinicians, they are often busy/scrubbed and then call back when we are with another patient
- Email often a more effective tool – ability to CC all relevant clinicians and the HNELHD-JHHPeriopnurse@health.nsw.gov.au perioperative nurse address.
- Provides a paper-trail of communication. Encourages multidisciplinary engagement.
- Clinician email addresses usually available on their letterhead/website.
- The urology registrars are setting up an email address to allow us to create a bank of patients for them to ask their consultants about on a regular basis.
Cardiac Investigations in this patient post initial Type 2 MI
- Interestingly this patient had a sestamibi which showed ‘no major area of inducible ischaemia’ and that patient had no chest pain throughout the protocol.
- Note that the stress ECG component of the test is difficult to interpret in the present of Ventricular-pacing.
- See article on non-invasive cardiac stress testing (http://dx.doi.org/10.1136/heartjnl-2015-307764).)
80yo man for L TKR.
- Episode of LOC several years ago
- Isolated event. Nil seizure-like features.
- Witnessed by family members
- Extensive review by neurologist – EEG showed prominent epileptiform features in the temporal lobe which were reproducible on repeat testing.
- EEG abnormalities resolved with commencement of Levetiracetam.
- Bifascicular block on ECG, HR 59, no cardiologist review
Should we be concerned about a cardiac cause for his LOC?
- Reassuring features:
- One distant episode.
- Now treated for epilepsy. No further episodes.
- EEG showed a gross abnormality and repeat EEG after treatment was normal.
- Concerning features:
- Episode doesn’t really sound like a seizure. Sounds more cardiac in origin.
- Unlikely that a cardiologist be interested in one episode of LOC
- Holter = low risk study however likely wasted resource and burdensome to patient
- Proceed with surgery without further investigations.
60yo female, for hysteroscopy and D+C for abnormal uterine bleeding.
- Refugee from Democratic Republic of Congo
- Arrived 2019.
- 10yrs prior spent in refugee camp with 6 daughters.
- Difficult consultation. Patient requesting only her daughter act as interpreter. Language barrier difficult, particularly on phone
- Conversion disorder
- Developed right sided full body pain, paraesthesia, and dysphagia (couldn’t swallow saliva) 2/7 after arrival in Australia.
- Extensive medical review – nil organic cause found.
- Management through HIPS.
- Most symptoms now resolved.
- Latent TB diagnosed on screening. No treatment.
- Not COVID vaccinated, currently considering.
Implications of latent TB perioperatively?
- Lack of literature around latent TB
- ID advised:
- Screen for symptoms – weight loss, night sweats, cough, haemoptysis
- If nil symptoms present, no specific precautions needed.
- Should ensure gynae team know that patient has latent TB, as all organs can be affected, seeding can occur, and staff exposure from surgical sites.
Video-consulting in perioperative clinic
- Facilitate improved communication in cases with communication barriers
- May also assist with patients who require visual assessment; concerns about frailty/airway, or if F2F consultation impossible or better to avoid (e.g. moving between zones with different COVID regulations)
- Video is challenging to arrange for all patients as it impacts on efficiency and patient satisfaction as patients must “wait” in a virtual waiting room.
- Audiovisual technology requirements – may be challenging for older patients but family and GP surgeries could help
- Video most beneficial as a targeted resource. May set up a specific clinic session for a group of patients to maximize clinic efficiency at other times.
53yo male for right hemicolectomy.
- Laparoscopic appendicectomy 12/12 ago, no issues.
- Mass found in Right Colon due appendicectomy
- ETOH binge drinker
- 5cm AAA, asymptomatic
- Incidental finding in workup for bowel cancer
- Now 5.5cm, requires treatment
- Patient reported having HBV previously
- On further investigation, diagnosed with HCV in 2015, with low titres.
- FibroScan – no cirrhosis. Planned for no active treatment but advised to await new treatments in the very near future.
- Lost to follow up after that.
EVAR v. Open repair AAA
- Concerns about longer recovery with open procedure, may delay cancer treatment
- Neurohumoral responses to major open abdominal surgery may accelerate cancer spread/progression
- On a population level, Uptodate suggests:
- Randomized trials comparing open AAA repair with EVAR have found significantly improved 30-day M&M for EVAR but no significant differences in long-term outcomes up to 10 years.
- A pooled analysis of these trials identified a 69% reduction in the risk for perioperative mortality for endovascular compared with open repair (odds ratio [OR] 0.33, 95% CI 0.17-0.64).
- EVAR appears to be associated with the need for more secondary procedures and an ongoing future risk of aortic rupture.
- If bowel surgery was more urgent (e.g. obstruction) would open or laparoscopic procedure be preferable with known large AAA? – unclear
- Abdominal CT often ordered by surgeons in suspected appendicitis in older age group, due to possibility of cancer
Role for HCV RNA PCR (BMJ best practice)
- Negative result confirms no current infection (whereas antibodies will always be +)
- Recommended 1st line test if immunocompromised, as antibody testing may be negative due to failed/delayed seroconversion
- Used to detect reinfection
- 15-45% of people will clear the virus spontaneously, so PCR tells you if they are viraemic.
- Proceed with EVAR
- HCV PCR – no need for titres. If PCR + will need treatment for HCV.
- Proceed with bowel cancer surgery regardless of requirement for HCV Rx.
- Check alpha-fetoprotein level to screen for liver cancer
69yo for hysterectomy. Open vs laparoscopic?
- Early endometrial cancer – hyperplasia. Nil local/distant metastases.
- Initial hysteroscopy surgically challenging, difficult to obtain biopsy
- Unable to access cervix, couldn’t insert Mirena.
- Distance patient, Dubbo
- Cognitive impairment, independent with ADLs. Attended with carer (niece).
- Challenging consult, limited history available
- AF, apixaban.
- BMI 45
- Hysteroscopy done under (uneventful) spinal due to being ‘unfit for GA’.
- History unclear, letters from cardiologist suggest fast AF several years ago, presumed rate-related Cardiomyopathy.
- EF was 25%, now improved to 60%
- NYHA III dyspnoea.
- Cardiologist visits from Sydney and regularly reviews at indigenous clinic
- Adrenal Mass
- Incidental finding. Large 38x22x36mm on staging CT
- Endocrinologists keen to Investigate as a possible functional mass. Pathology pending.
- On ACE-I and Beta-blocker so aldosterone/renin test unable to be performed until these medicines are paused.
- Potentially requires adrenalectomy
- Functional mass may have caused tachycardia and subsequent cardiomyopathy
Optimised from cardiac perspective?
- Recent TTE reassuring
- Remains dyspnoeic however BMI 45 and deconditioned are significant contributing factors
Endocrine Ix pre-operatively?
- Prudent to proceed with gynaecological surgery without significant delay.
- Mirena could not be inserted to slow the cancer progression.
- However a functional adrenal tumour will significantly alter management
- Urgent referral to endocrine completed after discussion with endocrine AT
Preoperative sleep studies?
- STOPBANG 7
- ESS = 5
- HCO3 = 29
- Spo2 =96% RA
- Some features to suggest possible Obesity hypoventilation Syndrome
- No preoperative sleep studies indicated given ESS < 8, urgency of surgery, and further delay.
Distance patients in clinic
- Gynae-oncology distance patients are booked to have anaesthetic consult and surgical review on same day
- Often travel long distances to the hospital and are seeing the anaesthetist first as the gynae clinics are in the afternoon
- Not ideal as we might not know what operation is planned
- Can liaise with the surgeon that afternoon
- Helpful to send patient to gynae appointment with photocopy of anaesthetic chart and a mobile phone number so that the team can rapidly access the information they need and contact us to facilitate surgery.
- Pathology including plasma metanephrines, 24-hour urinary catecholamines, TSH and Hb requested
- Urgent endocrine review via telehealth organised
51-year-old female for consideration of Posterior Lumbar Interbody Fusion for acute pain management
- Osteomyelitis and Discitis – current inpatient for pain management
- Multiple vertebral crush fractures
- E-coli bacteraemia – resolving
- No nerve root impingement/neurological symptoms
- COPD – current smoker. No formal spirometry
- Severe pulmonary hypertension and Tricuspid Regurgitation. Likely Cor-pulmonale
- Exercise tolerance – 50m on flat
- Recent ex IVDU with untreated Hepatitis C
- Childs-Pugh 3 Cirrhosis. Diagnosed following an upper GIH, gastroscopy showed varices.
- No regular gastroenterology follow-up or treatment
- Consensus that this is a high-risk patient and procedure.
- Undefined bleeding risk, need to assess preoperatively
- Gastroenterology advice should be sought preoperatively
Less invasive Surgical Options
- Main advantage to PLIF is analgesia, no neurological symptoms
- Neurosurgeon feels that vertebrae will self-fuse in coming weeks to months and results will be similar
- On discussion of co-morbidities surgical team have decided the procedure is currently too high risk for the indication
- Delay currently
- Neurosurgical team to organise Gastro consult
64-year-old lady for left shoulder second stage revision/replacement
- Infected Left shoulder replacement – long hospital admission with multiple washouts/removal of hardware/insertion of spacer
- Colonised with pseudomonas
- Severe asthma – multiple admissions to ICU postoperatively with Type 1 Respiratory failure requiring NIV
- NYHA Class 3 dyspnoea. Daily Ventolin x3. Regular prednisolone requirement
- Recently commenced Mepolizumab immunotherapy with excellent response in symptoms and no steroid requirement
- Novel therapy, not frequently encountered perioperatively
Management of Mepolizumab
- Ideal situation would be to continue given significant improvement in respiratory symptoms however uncertain effects on wound healing, infections rate with major joint surgery
- Absence of literature online
- Discussed with prescribing physician – Mepolizumab is a monoclonal antibody which targets human IL-5 with high affinity and specificity. IL-5 is the major cytokine responsible for the growth, differentiation, activation, and survival of eosinophils.
- Respiratory physician recommends continuation of therapy and has emphasized that there are no effects on neutrophils or other white cells
- Continue Mepolizumab as advised
- Discuss above with orthopaedic surgeons
43-year-old lady for Hysteroscopy/D&C
- Asthma and upper airway dysfunction – stable disease, well-controlled with inhaled therapies and regular respiratory review
- Cannabis smoker – daily
- Abnormal uterine bleeding – menorrhagia for 3/52 each month, using 6+ pads per day
- Bleeding significantly affecting QoL; unable to work, take children swimming.
- Fe-deficiency, no anaemia. 3 monthly iron infusions.
- Positive bleeding history – epistaxis x2 per week. Gum bleeding when brushes teeth.
- International Society of Thrombosis and Haemostasis (ISTH) Bleeding score = 4
- Normal range is <4 in adult males, <6 in adult females and ❤ in children
Preoperative interventions required?
- Discussed with haematology registrar, unusual pathology results; Factor VIII levels and antigens supra-normal indicating vWD unlikely
- Normal Full Blood Count, APTT slightly raised at 39
- Interestingly, lupus anticoagulant and fibrinogen were raised which would indicate a propensity for clotting rather than bleeding
- Urgent Haematology appointment organised – unlikely to occur preoperatively. Public outpatient system under pressure at present
- Consensus that it would be reasonable to proceed with above procedure
- Discussed with Gynaecology Fellow, agreed it is important to address bleeding while awaiting further haematology review
- Options for Mirena will be presented to patient as a short-term management
- Proceed to surgery
- Haematology review pending