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The imperfect opinions in these reports are only meant to stimulate discussion: - they should not be considered a definitive statement of appropriate standards of care. Date 22/7/21Attendance?: Paul Healey, Ben Porter, Claire Wohlfahrt, Nikhil Patel, Ashok Dharmalingham, Holly Kristensen, Hannah Morris, Lisa Doyle, Graeme Wertheimer, Greg Dale, Phil Beames, Ben Bartlett, Richard Leaver, Phil IC 1:Colonoscopy with recent PE72-year-old man for gastroscopy and colonoscopyBackgroundSurveillance colonoscopy for previous benign polypsGastroscopy for chronic GORD symptomsBMI 57NIDDM, good controlPAF, on ApixabanPulmonary Hypertension, routine echo in 2017IssuesRecent Bilateral PE’s (April 2021) with significant clot burdenAdmission with sepsis and AKI 2 months previously and DOAC ceasedNo investigations for OSA; STOPBANG 8 and Epworth Sleepiness Score 12Not known to respiratory physician and no follow-up in place from hospital admissionDiscussionShould procedure be postponed?Yes. Elective procedure. No red flags. Surgical team in agreement.Postpone until 6 months post PE. Postponement of 3 months is usually adequate. A longer timeframe was selected in this patient due to the severity of his disease and complex comorbidities.OptimisationReferral to respiratory physician; significant clot burden, should he have repeat imaging before interruption of anticoagulation?Clinical suspicion of OSA (and possibly OHS) given multiple risk factors, ESS, and long-standing pulmonary hypertension. Plan to discuss with respiratory physicianPlanPostpone for at least 3 monthsRepeat echocardiogramReferral to respiratory team TOPIC 2:Major Vascular Surgery and Angina49-year-old lady for complete endovascular reconstruction of Aortic bifurcation, endoluminal graft, and reconstruction of aorto-iliac segment.BackgroundSignificant peripheral vascular disease – intermittent claudication, limiting all exercise. Wheelchair bound outside homeMorbid obesityNIDDM. HbA1c = 5.8%IssuesRecurrent episodes of angina on minimal exertion over the last 3 monthsExercise stress echocardiogram performed – submaximal test due to leg pain. Exercised 3-4 METs and reached 69% of predicted heart rateChest pain during test, normal ECG and no exercise-induced Regional Wall Motion Abnormalities or reduction in end-systolic volumesCTCA recommended by treating cardiologistCTCA – Left main disease. ‘Extensive CAD with at least 50-69% stenosis in left main and mid RCA.’ Calcium score 439 (above 95th percentile)Discussed at cardiology meeting. Plan to postpone and perform coronary angiogramDiscussionCTCADiscussion as to the value of the test in this patientYoung patient but high calcium score not unexpected given existing vascular diseaseCoronary CTA VISION study – evaluated role of CTCA in perioperative risk stratification.Results showed patients were x 5 times more likely to have an inappropriate over-estimation of surgical risk based on RCRI after coronary CTA Coronary angiogram likely to be a better test in this patientLM diseaseCABG vs PCI discussedTraditionally, left main disease was an indication for CABGExtensive area of myocardium involved with increased potential for morbidity and mortalityEvolution of practice, newer generation of DES, and improved adjuvant drug therapy has created better outcomes for PCI in LMCA2 recent RCT’s EXCEL and NOBLE compared revascularization with PCI to surgical techniques with conflicting results. Both trials showed similar long‐term survival rates to CABG surgery, particularly in those with low and intermediate anatomic risk.?However, patients undergoing PCI had higher need for repeat revascularization in the future.Which patients are suitable for PCI? Current guidelines from AHA state they ‘strongly recommend surgical revascularization for LMCAD (class IA) with PCI considered a?reasonable alternative (class II) in select patients with less complex anatomy and clinical characteristics that predict an increased risk of adverse surgical outcomes.’ at cardiology meeting – to proceed to coronary angiogramPatient and surgeon aware of IC 3: Carotid Endarterectomy and triple vessel disease55-year-old lady for Right Carotid EndarterectomyBackgroundBilateral carotid artery stenosis: Right 99%, Left 90%Symptomatic – multiple TIAs with left hemiparesis. Right temporoparietal watershed infarct on MRIVertebral artery disease – possible small dissection on imagingNIDDM. HbA1c = 6.7%IHD with multiple previous PCI’sIschaemic cardiomyopathy, LVEF 45%Issues:Recent NSTEMI (in WA) Significant triple vessel disease on angiogramTreating team felt CVA risk too high for CABG, opted for PCIPCI in June 2021: 1x DES to prox RCA, 1x DES to Mid-Cx, 3x overlapping DES to LAD Now on TicagrelorRecent echo showed hypokinesis of inferior and septal wallsDiscussionComplex and high-risk cardiac and cerebrovascular disease!Management of anti-platelet therapyTicagrelor - oral, reversible, direct-acting P2Y12 inhibitor. Ticagrelor has a more rapid onset and more pronounced platelet inhibition than clopidogrel. See attached PLATO trial.Vascular surgeon happy to perform CEA on Aspirin/Clopidogrel but not on Ticagrelor due to increased bleeding risk.Current plan to cease Ticagrelor 3 days preoperativelyUnclear if patient was on DAPT when had recent NSTEMIIf had NSTEMI on Clopidogrel, should we consider performing platelet function studies?Discussed at Cardiology meeting – DAPT would be ideal solutionTiming of ProcedureBooked for September, 3 months post-PCIConsensus is that it would be acceptable to proceed earlier given significant disease and ongoing risk of CVAProcedural IssuesShunt – bilateral disease along with possible vertebral artery dissection, would the proceduralist opt to shunt prophylactically?Majority felt that shunt would be most likely performed in this case but should be discussed further with proceduralist DispositionPostoperative ICU for strict BP control and haemodynamic monitoringShould we consider postoperative troponins?Plan:Further discussion required with proceduralist and cardiologist regarding timing of surgery and management of antiplatelet medicationsPostoperative ICU bedTOPIC 4: TKR and OSA 76-year-old lady for elective TKRBackgroundSignificant knee pain, impacting QoLCOPD, mild. 60 pack year smoking historyCeased smoking to facilitate TKRPeripheral vascular disease, multiple revascularization procedures. On apixabanBMI 46NIDDM. Poor glycaemic controlDifficult to obtain accurate history in clinicSome indications of poor medication complianceOn ?CPAP for OSA. Advised to bring to hospital.Extensive perioperative work-up, including delay to improve glycaemic controlIssuesPresented for TKR. Uneventful intraoperative course.Developed Type 2 respiratory failure in PARUHome machine not functioning due to water ingress, sent to biomedCommenced on NFNP with little effectReviewed by respiratory CNC in PARU. Patient well known to servicePatient has significant OHS and is on home BiPAP (IPAP 17, EPAP 9)Device history revealed recent non-compliance with therapyRespiratory department sourced a replacement machine.Patient stable in recovery on usual BiPAP settings and discharged to ward.DiscussionConduct of anaesthesiaSpinal with intrathecal morphine 100mcg – consensus opinion that this was the optimal anaesthetic choice as avoided parenteral opioids.Some anaesthetists routinely use 150mcg morphine but would decrease to 100mcg in patients at risk of postoperative respiratory depressionConsensus in literature than 100mcg is optimal dose for avoidance of respiratory depressionCould this situation have been avoided?Difficult history, multiple complex comorbiditiesPatient unaware of differences between CPAP and BiPAPNon-compliant with therapy Respiratory CNC provided extremely valuable input and avoided an unplanned HDU admissionPerioperative management of suspected OSA/OHSClinic guideline under development, ongoing discussions with respiratory dept Sleep studies are time-consuming and turnaround time from referral to initiation of CPAP is around 6 monthsNo RCT evidence to support reduction in perioperative morbidity and mortality with initiation of CPAP therapy. Observational data would suggest that OSA patients have worse perioperative outcomes and there are benefits to initiating CPAP perioperatively. (Anesth Analg 2015;120:1013–23)Aim is to identify those at highest risk of postoperative pulmonary and cardiac complications OHS – more complex sleep disorder with raised HCO3 and PaCO2. Majority also have OSA. These are patients to identify and treat perioperatively.Perioperative assessment: STOPBANG (>3) then perform ESS. If ESS (>8) – consider referral for sleep studiesTOPIC 5: EVAR with severe COPD83-year-old lady admitted to hospital with abdominal pain. Incidental finding of 6.4cm infra-renal AAABackground Severe COPD, recently commenced on home oxygenRecent admission with infective exacerbation Type 1 respiratory failure, Room Air PaO2 = 55mmHgSpirometry - FEV1/FVC: 0.99/1.48: 0.67. TLCO 37%HFpEF. 1.5 litre fluid restrictionPulmonary hypertension, moderateLarge hiatus hernia with uncontrolled GORDSevere kyphosisIssuesIncidental finding of AAA, suspicion of leak on scan Ongoing abdominal painHaemodynamics and Haemoglobin stableDiscussion pointsShould surgery proceed?Large aneurysm, annual rupture rate around 10%Respiratory physician opinion that survival from COPD is “a few years.”Patient keen for procedure, has supportive family and great-grandchildren nearbyNot suitable for an open procedurePatient and family fully aware of risksOptimisationEchocardiogram? Enable assessment of LV function and Pulmonary hypertension – not likely to change managementConduct of AnaesthesiaSedation vs GA vs epiduralPatient can lie flat without significant dyspnoea, but procedure expected to last around 90 minutes Breath-holds required and can be painfulAspiration a concern with sedationGA may facilitate faster procedureAim to extubate at end of caseEpidural may prove difficult given kyphosisDispositionICU bed if GA/any complications ................
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