Complex Disease Perioperative Management Flashcards
16A10 A patient with known primary pulmonary hypertension is scheduled to undergo elective umbilical hernia repair.
a) How will you assess the severity of this patient’s pulmonary hypertension? (50%)
b) How does this diagnosis affect your perioperative management of this patient?(50%)
A)
History - WHO Functional Class, History of RHF, Diagnosis Timeline & Progression of Disease, Current Medication eg mono/triple therapy, Recent hospitalisation or VTE, PMH esp IHD, Recent Cardiology Letters.
Examination - Vitals + Signs of RHF
Investigation - RHC - >55mmHg severe, TTE (RHV, RHF, TAPSE <16mmHg), 6MWT <400m severe
B)
Pre op/ MDT -> risk/benefit of operation
depending on severity - transfer to larger centre if mod/severe or signs of RHF
preoptimisation - eg diuretics, pulmonary vasodilators
Intraop
Choice between GA/neuraxial
GA - control over ventilation/ haemodynamics. However, drugs may decrease preload, afterload and inotropy - leading to RHF
Neuaxial - unpredictable effect on SVR leading to loss of ventricular interdependance and decrease CO. However - maitain spont vent, excellent analgesia
Monitoring - must have IAL, 5 lead ECG, Temp probe
Staff - if severe consider second senior anaesthetist
Plan for pulm HTN crisis - eg support RV, decrease PVR (nitric)
Surgeon - consultant to operate - need to minimise time
Post Op
HDU for haemodynamic monitoring
Ensure excellent analgesia but avoid over sedation with opioids
47M with chronic alcohol misuse presents with abdominal pain and requires laparotomy
Describe how alcohol misuse will affect your perioperative managment
Pre
Determine severity of misuse and end organ damage
CVS - cardiomyopathy/heart failure, HTN , arrhythmia (AF,SVT,VT) -> ECG
CNS - wernicke-lorsakoff encephalopathy , autonomic neuropathy
Liver - chronic liver disease and sequale
Bone Marrow - pancytopaenia , –> Hb, platelets
Metabolic - hypokalaemia, hypomagnesaemia, hypoglycaemia
Intra
Induction - IAL if cardiac disease
RSI –> laparotomy but also risk of autonomic dysfunction
Bleeding - if CLD replace products as per ROTEM - INR/PT unreliable
Drugs - if chronic use and not intoxicated will need higher doses of anaesthesia , balanced with careful induction if septic or cardiac disease
- reduce propofol dose, increase fentanyl dose, use BIS once asleep to minimise volatile
NMBD - rocuronium likely to last longer - would still use as needs RSI but would place neuromuscular monitor on and check best extubation
Po
High periop risk –> deliruim (independant risk factor), admisson to HDU/ICU, increased length of stay, increased bleeding . Altered immune response due to leucopaenia –> eg surgical site infection, LRTI and UTI
Monitor for delirium and withdrawl
Analgesia prevent delirium
If severe end organ disease –> HDU
