Hysterectomy, severe cardiomyopathy

69yo for hysterectomy. Open vs laparoscopic?

Background

  • 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

Issues

  • Cardiomyopathy
    • 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

Discussion

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.

Plan

  • Pathology including plasma metanephrines, 24-hour urinary catecholamines, TSH and Hb requested
  • Urgent endocrine review via telehealth organised

PLIF, cirrhosis

51-year-old female for consideration of Posterior Lumbar Interbody Fusion for acute pain management

Background

  • Osteomyelitis and Discitis – current inpatient for pain management
  • Multiple vertebral crush fractures
  • E-coli bacteraemia – resolving
  • No nerve root impingement/neurological symptoms

Issues:

  • 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

Discussion

Perioperative Optimisation

  • 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

Plan:

  • Delay currently
  • Neurosurgical team to organise Gastro consult

Immunosuppressant, major arthroplasty

64-year-old lady for left shoulder second stage revision/replacement     

Background

  • Infected Left shoulder replacement – long hospital admission with multiple washouts/removal of hardware/insertion of spacer
  • Colonised with pseudomonas

Issues

  • 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

Discussion

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

Plan

  • Continue Mepolizumab as advised
  • Discuss above with orthopaedic surgeons

Undiagnosed bleeding disorder, hysteroscopy

43-year-old lady for Hysteroscopy/D&C

Background:

  • Asthma and upper airway dysfunction – stable disease, well-controlled with inhaled therapies and regular respiratory review
  • Cannabis smoker – daily

Issues

  • 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 
Timeline

Description automatically generated
  • Normal range is <4 in adult males, <6 in adult females and ❤ in children

Discussion

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

Surgical Options

  • 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

Plan: 

  • Proceed to surgery
  • Haematology review pending

von Willebrands Disease and Gynae Surgery

60-year-old lady for laparoscopic BSO – Preventative surgery

Background

  • Family history of Ovarian Cancer
  • Mild Asthma – No admissions or steroids. 
  • Hypertension – single agent

Issues

  • 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.

Discussion

Coagulation Screening in Perioperative Clinic

Diagram

Description automatically generated

Transfusion reaction

  • Most likely scenario is symptoms were attributable to massive transfusion
  • Early Group and screen for antibodies to identify any specific blood requirements preoperatively

Role for Thromboelastography?

  • Evolving research in this area, especially in the acute and perioperative settings.
  • TEG parameters of K-time and MRTG have been found to be effective in detecting patients with vWF:Rco < 30IU/dL (Diagnostic value <60)
  • See attached article on bleeding disorders and anaesthesia

Plan

  • Chase Haematologist letter and inform local team preoperatively to ensure we have all possible products required
  • Postpone surgery for shortest possible time until haematology review occurs.

TURBT v. parotidectomy

  • 69-year-old lady for TURBT. 
  • Incidental finding of large bladder tumour on surveillance imaging.  No haematuria/obstructive symptoms

Background:

  • Non-small cell lung cancer – Stage IV with Brain metastases, complete response to palliative radiotherapy
  • Right parapharyngeal mass on previous surveillance PET.
  • Asymptomatic. Biopsy showed atypia but ENT surgeons concerned about change in size and shape of mass. 
  • Listed for parotidectomy (cat 2)

Issues

  • COPD, moderate disease FEV1/FVC = 0.6 (79%). 50 pack year smoking history
  • Significant deconditioning; 3.9 METS on DASI. Walks 20-30m with stick or 4WW
  • Clinical depression with suicidal ideation. Rarely leaves home
  • Iron deficiency
  • Reviewed at perioperative clinic 6/12 ago
  • Referred for prehab, very motivated family but on hold currently due to COVID
  • No change since last clinic review 

Discussion

Which Surgery Should Proceed First?

  • Consensus that TURBT should occur
  • Large bladder tumour with potential for obstructive symptoms
  • Urologist is aware of patient limitations and prepared for a debulking procedure if surgery is technically difficult
  • ENT procedure needs to be done but pharyngeal mass not malignant and remains asymptomatic
  • Imperative to update ENT surgeons of delay of at least 6 weeks

Optimisation options

  • Clinical issues – deconditioning and Fe-deficiency both being addressed
  • Depression is severely impacting functional capacity
  • Prehabilitation – psychological as well as physical benefits; social aspect advantageous in isolated people
  • GP manages depressive symptoms, on multiple pharmacotherapies with little effect
  • Letter to GP in May regarding possibility of specialist input but nil yet.
  • Psychiatry and psychology services currently very difficult to obtain

Plan: 

  • Fe-infusion and proceed to TURBT
  • GP letter regarding psychiatrist and/or psychologist for optimisation of mental health symptoms
  • Prehab can occur pre-ENT surgery
  • Discussion with family around Advanced Care Planning 

Bladder botox, IHD

94-year-old lady for bladder Botox

Background

  • Urinary incontinence
  • Previous bladder Botox minimally successful
  • CKD – Stage 2
  • NIDDM
  • Severe OSA – on CPAP
  • Chronic Back pain – laminectomy in 2018

Issues

·       Extensive IHD – Multiple previous admissions with ACS requiring PCI. 

  • Ischaemic cardiomyopathy – Recent Sestamibi: LVEF 36% and fixed LAD territory abnormality
  • Type II MI and episode on non-sustained VT associated with anaemia (Hb=66).
  • Suspected upper GI bleed as cause of anaemia. Conservative management by gastroenterologist. Aspirin ceased and clopidogrel continued.
  • Cardiologist has advised she should continue clopidogrel and is ‘unsuitable for any procedure’ during recent anaesthetic clinic review at Maitland

Discussion

Management of antiplatelet agent

  • Surgical team have requested 7 day-cessation of clopidogrel
  • Discussed cardiac history with team, they are concerned regarding bleeding on clopidogrel but happy to recommence aspirin
  • Is it appropriate to recommence aspirin in setting of suspected upper GI bleed?
  • Previous bladder Botox performed on DAPT but team felt surgical bleeding was unacceptable. Uneventful GA. 
  • Risk of further Type II MI with bleeding 

Plan

  • Face to face review in clinic
  • Liaise with gastroenterologist for advice regarding aspirin

Consult for TKR, polymorbidity

73-year-old man referred by medical team for consideration of TKR. Previously considered too high risk for surgery but had recent CABG with uneventful perioperative journey.

Background

  • Osteoarthritis knee – wheelchair-bound
  • Paroxysmal AF – Warfarin and Bisoprolol
  • Chronic Renal Disease – Stage 2
  • Chronic bilateral lymphoedema
  • Pseudogout
  • Inflammatory arthritis – two previous episodes of septic arthritis in Right knee
  • Increased BMI

Issues

  • IHD – Stable disease post-surgical revascularisation. Emergent procedure in setting of NSTEMI. 
  • Poor Glycaemic Control – HbA1c on last admission 9.8% (in context of recent major surgery). Random BSL at clinic 16 mmol/L.
  • Deconditioning and significant immobility 
  • Chronic pain – On hydromorphone. Unable to tolerate NSAID’s due to renal disease.

Discussion

Recent Cardiac Revascularisation

  • Cardiology review and echocardiogram normal
  • CABG done in setting of NSTEMI and refractory angina requiring GTN infusion
  • Currently on aspirin and warfarin
  • Timeframe post-NSTEMI should be considered despite surgical revascularization.

Glycaemic control for major joint surgery

  • The current guidelines are HbA1c<7.5% for major joint replacement.
  • SGLT-2 or GLP-1 receptor agonist are excellent options to improve glycaemic control and aid weight-loss. This should be physician-led.

Increased BMI and Immobility

  • Limited due to OA and knee pain
  • Dietician – very difficult to access at present. GP/endocrinologist most effective pathway
  • Physiotherapy input. Consider cardiac rehabilitation programme?
  • Currently awaiting appointment with HIPs – will have access to allied health also.

Physician-led referral

  • Excellent opportunity for perioperative optimisation in conjunction with medical team
  • Difficult to prepare a patient for surgery until we know he is a candidate
  • Issues are mainly surgical, suitability for procedure can only be assessed by surgeon

Plan

  • Refer to physician with above recommendations to optimise for surgery
  • Recommend surgical review