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
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
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?
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
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
60-year-old lady for laparoscopic BSO – Preventative surgery
Family history of Ovarian Cancer
Mild Asthma – No admissions or steroids.
Hypertension – single agent
Bleeding Disorder – Patient unsure of name of condition, knows it is a platelet problem.
Normal FBC and Coagulation Screen
VWD most likely diagnosis
First diagnosed 30 years ago – presented with epistaxis
PPH after all births
Life-threatening intraoperative haemorrhage requiring massive transfusion and ICU admission following elective D&C/Cone Biopsy
Brother died following post-tonsillectomy bleed
Telehealth Consult with haematologist recently – No letter available. Patient states they recommended Tranexamic acid and platelet cover preoperatively and oral tranexamic acid for 10 days postoperatively
Concern about possible transfusion reaction – describes dyspnoea and lip swelling during massive transfusion episode
Undergone 2 subsequent orthopaedic procedures with no bleeding – femoral nail in Japan and revision of femoral nail in Sydney. Both procedures performed under platelet cover.