Tag optimisation

Phone consultations in clinic, missed pre-op optimisation?

garychleung

PIG Meeting: 4th March 2021

Case one:

64yo male for lap high anterior resection for sigmoid polyp unresectable at colonoscopy.

PHx: HTN, dyslipidaemia, obesity BMI 33, smoker, chronic mild hyponatraemia (thought secondary to alcohol misuse)

On day of surgery:

  • Identified in the bay as high risk for OSA (STOP-BANG 6, body/facial habitus highly suggestive)
  • Conversion to laparotomy after failed initial anastomosis.
  • Pain well controlled with multimodal analgesia (TAP catheters, ketamine intra-op, opioids, COX2i, paracetamol)
  • Extended observation in PARU to ensure sedation/respiratory depression v. Analgesia favourable.
  • Referred to ICU outreach for closer observation overnight.
  • Nil issues arose.

Discussion:

Visual cue of the obese patient may lead to missed identification of patients at risk of OSA.

ICU outreach can provide a valuable tool for patients identified as at increased risk for an adverse perioperative outcome.

Case two:

74yo male for TAMIS resection of rectal polyp.

PHx: HTN, severe vertebrobasilar disease, BMI 34. Atrial ectopy on ECG from 18mths prior.

On day of surgery:

  • Identified at time of positioning for SAB as having irregular pulse and cardiac output on arterial line (arterial line used due to severe cerebrovascular disease)
  • 12 lead ECG difficult to interpret, initial showing ? Atrial ectopy, then a second trace showing atrial flutter with variable block.
  • Electrolytes normal
  • Corridor consultation with two anaesthetists regarding decision to proceed or cancel. Precancerous lesion (i.e. non-urgent surgery) v. Clopidogrel already withheld 7days exposing patient to stroke risk v. Poor usage of theatre time v. Patient expectations v. Already significant delays on the day due to surgical misadventure with previous patient…Decision to proceed.
  • HR dropped to 40 with colonic insufflation with ~5-6 flutter waves before a ventricular complex, BP maintained, ? CHB.
  • Treated with atropine, appeared to respond initially but not with a second episode.
  • Pads placed in case pacing required. Isoprenaline sourced.
  • Discussed with cardiology AT
    • Patient admitted to monitored bed (G3) overnight.
    • Formally diagnosed with atrial flutter.
    • Plan for commencement of Apixaban once surgeons satisfied bleeding risk passed.
    • Discharged home, plan for referral to cardiologist and for TTE, by GP.
  • Could this situation have been avoided with a face-to-face consultation?
    • Physical examination and ECG in clinic would likely have identified the issue
    • ECGs can be requested (e.g. from GP) even with phone consultations in patients who meet the preop criteria.
    • Age > 50 (men), > 60 (women)
    • Cardiac disease as evidenced by history or exam
    • Presence of cardiac risk factors
    • On further questioning, this patent did actually have a history of palpitations and was awaiting investigation by the GP.
  • How should this patient have been worked up prior to non-urgent surgery?
    • Check serum electrolytes
    • TFTs
    • TTE to look for structural heart disease
    • Cardiologist review for rate control, treatment of active precipitating disease processes, anticoagulation and consideration of electrical or pharmacologic cardioversion.

Elderly patient with severe heart disease for laparoscopic cholecystectomy

garychleung

PIG Meeting: 4th March 2021

73yo male booked for lap chole due to recurrent choledocholithiasis

Background

  • Choledocholithiasis – several admissions with sepsis requiring IV Abx and ERCPs
  • Cardiac disease
    • Missed STEMI 2019 – DES to LAD, LCx occluded, not amenable to PCI
    • Polymorphic VT arrest 2019 2 days post ERCP, hypokalaemic.
    • 2nd polymorphic VT arrest 2/7 later (K+ normal)
    • AICD placed, nil shocks since.
    • Bisoprolol and amiodarone
  • Paroxysmal AF – on dabigatran
  • GORD
  • Smoker
  • Ex tolerance 5 METS as per DASI

Issues

  • Cardiac status
    • TTE – EF 30-35%, stage I diastolic dysfx, mild MR, mild AR, e/o inferolateral RWMAs, biatrial moderate to severe enlargement.
    • Reviewed by cardiologist – Nil current e/o CCF, exercise tolerance only mildly limited

Discussion

  • Should he have surgery?
    • SORT score 5.4% risk of death
    • Severe cholangitis in this man carries a high risk of morbidity and mortality, as does emergency surgery.
    • While his risk of death with elective surgery is not insignificant it is likely the lower risk option.
  • Opportunities for optimisation?
    • Cardiologist r/v suggests HF reasonably controlled. Suggested ceasing Dabigatran 48h preop and switching to aspirin until resumption of anticoagulation.
  • Postoperative care location
    • >5% risk of perioperative mortality widely considered to represent ‘high risk’ however limited ICU bed spaces necessitates thoughtful rationing of resources.
    • Extended recovery (i.e. 4hr stay) is a useful option – observe for dysrythymias, replenish electrolytes as needed, support normal physiology then, provided no issues arise, discharge to normal ward.