Pre Op Assessment : When not to operate?

Dr. Sanjay Wijayatilake BSc.(Hons), MB BS, FRCA, FFICM

Honorary Clinical Senior Lecturer QMUL

Clinical Lead Neuro Intensive Care

Mr. J.W.83 year-old gentleman.

Diagnosed with a left frontal meningioma in July 2012 after being investigated for gait and speech disturbance.

Extensive co-morbidities:CVS: hypertension, hypercholesterolaemia, atrial fibrillation, mixed aortic valve disease – moderate stenosis, mild regurgitation – LVEF 50-55%.Other: stage 3 chronic kidney disease, chronic obstructive pulmonary disease, prostate cancer, bladder cancer.Exercise tolerance 10m on level ground.

Mr. J.W.

Initially declined surgery in 2012.

Admitted to hospital 24th May 2013 with a 20 minute tonic-clonic seizure.

Acute CT head showed frontal vasogenic oedema with mass effect.

Started on dexamethasone and phenytoin.

Discharged 2nd June with outpatient neurosurgery appointment on 4th June.

Mr. J.W.Seen in clinic, agreed for surgery to be done on 14th June.

Clinic entry in notes states pre-operative anaesthetic assessment required as high-risk patient.

NO pre-operative anaesthetic assessment documented in notes.

Pre-operatively10th June saw GP for “excess phelgm on chest” and started on course of amoxicillin.

13th June admitted to hospital pre-operatively.

Respiratory section in neurosurgical admission clerking crossed out!?!!

Examination findings documented as “wheezy ++” and “scattered creps”.

No respiratory rate or oxygen saturation documented.

Pre-operativelyAmoxicillin documented in medication history along with date of initiation.

Anaesthetic chart documents “wheezy” in pre-operative section.

Medications documented as “see list, 15 drugs”

No pre-operative anaesthetics examination documented.

No pre-operative observations documented.

Pre-operativelyRoutine bloods:

Hb 145, MCV 94.2, plt 119

WCC 5.1, Nø 3.4, Lø 1.0, Mø 0.6, Eø 0.0, Bø 0.0

Na+ 140, K+ 4.3, Ur 9.6, Cr 101

Bili 11, ALP 94, ALT 34, alb 34

CRP 77

Intra-operatively

4 hour, 15 minute long operation.Started 0930hr / Finished 1345hr

General anaesthetic:Ketamine. /Propofol /Isoflurane.

50% FiO2 required throughout entire operation.

SpO2 dropped from 99% to 90% at 3 hour mark, no documentation of any intervention.

Post-operativelyIn theatres recovery for prolonged length of time.

Entered at 1359hrNo documentation of departure time.

SpO2 99% on 5L O2

Sudden desaturation at 2 hour mark, no documentation.

2 arterial blood gas print outs taped to anaesthetic chart, no documentation of events.

Post-operativelyFirst arterial blood gas at 1604hr:pH 7.319 pCO2 6.39, pO2 7.62 HCO3

- 24.1, BE -2.4SaO2 87.2%No FiO2 documented on print-out, 2L O2 on NITU clerking.

Second arterial blood gas at 1618hr:pH 7.304 pCO2 7.42, pO2 28.74 HCO3

- 27.0, BE -0.3SaO2 99.3%Again, no FiO2 documented on print-out, 40% O2 on NITU clerking.

Post-operativelySeen by NITU at 1900hr, noted “wheeze ++ everywhere” and “better on BiPAP” - intially

Combative and agitated on BiPAP as evening wore on. Becoming hypoxic.

Intubated at 2300hr.

In NITU

Further history obtained:Started on oral antibiotics 4 days pre-op.Was not improving so went back to GP and dose was increased.

Marked secretions suctioned via endotracheal tube.

Trial of extubation 19th June – failed due to secretions and no cough.

Percutaneous tracheostomy done 21st June.

In NITUMultiple positive sputum and swab cultures.

Heavy growth candidaHeavy growth Acinetobacter baumani

Resistant to amoxicillin and gentamicinHeavy growth Coliform spp.

Resistant to amoxicillin, co-amoxiclav, gentamicin, ciprofloxacin, piperacillin-tazobactam

Moderate growth Staphylococcus aureus

Outcome

Nearly a month-long stay in NITU.

Slow, prolonged respiratory wean.

No problems arising from craniotomy

Serial CTs – reduction in frontal lobe swelling, resolution of midline shift.

Key pointsFailure to act on pre-operative findings of wheeze, community antibiotic therapy, and raised CRP.

Poor to absent documentation of assessment, events and interventions.

Prolonged, expensive, NITU stay for largely respiratory problems.

(40 days on Neuro ITU cost the NHS approximately £50,000 ! Money which could surly have been better spent?)

Questions

Could this have been prevented by delaying the operation by several more days?

Could this have been prevented by performing an awake craniotomy rather than a general anaesthetic?

Literature reviewRelative paucity of modern literature on adults with active chest infections receiving a general anaesthetic.

Multiple case reports and observational studies involving children with URTIs and LRTIs:

Recurring theme of cough and normal chest x-ray pre-operatively with intra-operative desaturation and pulmonary collapse.One observational study using arterial catheters showed 2 to 7-fold incidence of SpO2 < 95% for > 5 minutes in children with URTIs.

Literature reviewMultiple large observational studies looking at peri-operative respiratory events in smokers:

One Japanese paper showed relative risk of 1.8 of respiratory events in patients with chronic bronchitis compared to non-smokers.

Laryngospasm, bronchospasm, hypoventilation, hypoxaemia.

American study showed odds ratio of 5.5 for post-operative pneumonia in smokers.

No evidence that pre-operative antibiotic therapy reduces the incidence of post-operative pneumonia in patients with COPD.

Literature review

Multivariate analysis attempting to develop a predictive model of pre-operative factors influencing post-operative pneumonia:

Pre-operative sputum production – 56% vs. 21%, p =0.005Surrogate marker of active chest infection.

SummaryPreventable post-operative complication.

Costly one month stay on NITU could have been avoided by delaying surgery.

Importance of acting on pre-operative assessment and investigations.

Medicolegal implications of poor documentation in preventable post-operative complication.

Literature shows that active chest infection significantly increases risk of post-operative pneumonia.

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Bluman LG, Mosca L, Newman N, et al. Preoperative Smoking Habits and Postoperative Pulmonary Complications. Chest. 1998; 113(4):883-889

Laszlo G, Archer GG, Darrell JH, et al. The diagnosis and prophylaxis of pulmonary complications of surgical operation. Br J Surg, 1973;60: 129–134

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Santandreu VJ, Penalba AS. Pulmonary atelectasis during anesthesia in a boy with upper respiratory tract infection. Rev Esp Anestesiol Reanim. 2001 Apr;48(4):188-91.

Taguchi N, Matsumiya N, Ishizawa Y, et al. The relation between upper respiratory tract infection and mild hypoxemia during general anesthesia in children. Masui. 1992 Feb;41(2):251-4.

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Schwilk B, Bothner U, Schraac S, et al. Perioperative respiratory events in smokers and nonsmokers undergoing general anaesthesia. Acta Anaesthesiologica Scandinavica, 41: 348–355.