2023.1 Day 2 VIVA 2

Peri-operative Medicine

You are currently in pre-admission clinic and are seeing this patient for the first time. He is a 62 year old man who has been scheduled for a Category 2 (SemiUrgent within 90 days) elective Laparoscopic Cholecystectomy for recurrent biliary colic. Surgery is planned for two weeks from today.

Past Medical History:

• Type 2 Diabetes Mellitus

• Hypertension

• Ischaemic Heart Disease (coronary stents 2 years ago, stable)

• Ex-Smoker (40 pack years)

• 110kg, BMI 35.4

Medications:

• Atorvastatin 40mg daily • Aspirin 150mg daily

• Atenolol 50 mg daily

• Ramipril 5mg daily

• Empagliflozin 25mg daily

• Metformin 1000mg XR daily

• Clopidogrel 75mg daily

• Glargine Insulin (Lantus) 40 units nocte

Examination:

• BP: 150/95, HR 60, Temp 36.5 oC, SpO2 94% (Room Air)

• Chest: scattered rhonchi on auscultation

• Heart: HS dual, no murmur

How would you further assess this patient prior to their procedure?

Type 2 Diabetes Mellitus:

• Assess glycemic control (HbA1c, recent glucose trends).

• Screen for diabetic complications (neuropathy, nephropathy).

Hypertension:

• Confirm adequacy of control (target <140/90).

• Check for end-organ damage (renal function, ECG for LVH).

Ischaemic Heart Disease (IHD):

• Review stent type (drug-eluting vs. bare-metal) and time since stenting.

• Assess functional capacity (METs, exercise tolerance).

• Consider stress testing if poor functional capacity or recent symptoms.

Ex-Smoker & Obesity:

• Screen for COPD (spirometry if symptomatic, optimize bronchodilators).

• Assess for OSA (STOP-BANG questionnaire, consider sleep study).

• Evaluate GERD risk (aspiration precautions if symptomatic).

Airway Assessment:

• Mallampati score, neck mobility, dentition.

Suitability for Local Hospital (Scenarioville):

• Ensure experienced surgical & anaesthetic team for high BMI/OSA.

What investigations would you order?

• Bloods: FBC, U&E, HbA1c, coagulation profile.

• ECG: Assess for ischemia, arrhythmias.

• Echocardiogram: If poor functional capacity or unexplained dyspnea.

• CXR: If COPD/asthma symptoms or signs of infection.

• PFTs: If significant respiratory symptoms.

How would you assess his functional capacity?

METs (Metabolic Equivalents):

• Can he climb 2 flights of stairs (4 METs) without symptoms?

• If <4 METs, higher cardiac risk; consider further cardiac workup.

Duke Activity Status Index (DASI):

• Formal assessment of exercise tolerance.

What are the anaesthetic concerns related to his obesity?

• Airway: Higher risk of difficult intubation, rapid desaturation.

• OSA: Postoperative hypoventilation, need for CPAP.

• Pharmacokinetics: Altered drug distribution (e.g., opioids).

• Positioning: Pressure injuries, nerve damage.

Would you proceed with surgery in Scenarioville?

Proceed if:

• Stable IHD, no recent symptoms, adequate METs.

• OSA managed (CPAP available post-op).

• HDU available for high-risk monitoring.

Defer if:

• Unstable cardiac/respiratory status or inadequate resources.

How would you optimise his medical conditions?

Diabetes:

• Aim for HbA1c <8%, adjust insulin perioperatively.

• Stop empagliflozin (SGLT2i) 2–3 days pre-op (risk of DKA).

Hypertension:

• Optimise ramipril/atenolol (continue perioperatively).

• Target BP <140/90; consider adding amlodipine if uncontrolled.

COPD:

• Smoking cessation reinforcement.

• Optimise bronchodilators, consider steroids if active wheeze.

How would you manage his antiplatelets?

Aspirin & Clopidogrel:

• Continue aspirin (low bleeding risk in laparoscopic surgery).

• Discuss clopidogrel cessation with cardiology (high bleeding risk vs. stent thrombosis).

• If recent stent (<6–12 months), may need bridging therapy.

What adjustments would you make to his insulin regimen?

• Pre-op: Reduce glargine by 20% if fasting.

• Intra-op: IV insulin sliding scale if prolonged fasting.

• Post-op: Monitor glucose Q2H, restart SC insulin once eating.

Would you continue his ACE inhibitor?

• Continue if well-controlled BP.

• Hold on morning of surgery if prone to intraoperative hypotension.

What preoperative counselling would you provide?

• Fasting instructions (6h solids, 2h clear fluids).

• Medication adjustments (SGLT2i cessation, insulin changes).

• CPAP use post-op if OSA diagnosed.

The patient develops ST elevation intraoperatively. What would you do?

Immediate Actions:

• Call for help (anaesthetic/surgical/cardiology).

• 100% O₂, ensure hemodynamic stability (IV fluids, vasopressors if needed).

• 12-lead ECG to confirm STEMI.

• Troponin, ABG, lactate.

Medical Management:

• Aspirin 300mg, heparin bolus if no bleeding risk.

• GTN infusion if BP permits.

• Beta-blocker if no contraindications.

How would you manage him in PACU?

• Continuous monitoring (ECG, SpO₂, BP).

• Serial troponins (0, 3, 6h) + repeat ECG.

• Echocardiogram to assess LV function.

• Cardiology consult for possible PCI.

What disposition would you recommend?

• CCU/HDU for ongoing monitoring.

• Post-op cardiology follow-up for stent surveillance.

Would you cancel the surgery if STEMI occurred pre-induction?

• Yes, defer for cardiac stabilisation (PCI if indicated).

• Reassess urgency (may need interval cholecystectomy).

What long-term changes would you recommend?

• Cardiac rehab, strict glycemic/BP control.

• Re-evaluate antiplatelet regimen (DAPT duration)

Key Phrases for High Marks:

• "Given his DES stents 2 years ago, I’d consult cardiology about clopidogrel cessation."

• "I’d stop empagliflozin 3 days pre-op due to DKA risk, and adjust his insulin."

• "For intraoperative STEMI, my priority is hemodynamic stability, aspirin, and urgent cardiology review."