# 2024.1 Day 1 VIVA 3

A 62-year-old female has presented to the anaesthetic clinic for review. She is scheduled for a laparoscopic assisted vaginal hysterectomy in 1 month.&#x20;

The clinic nurse tells you she has rheumatoid arthritis and has requested her medication list be faxed from the local GP.

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<summary>What specific features from history and exam would you elicit from this patient?</summary>

**Disease-specific history**:

* Duration and severity of RA (years, progression pattern)
* Current disease activity (active flare vs remission)
* Systemic manifestations (cardiac, pulmonary, renal involvement)
* Cervical spine involvement (pain, radicular symptoms, mobility)
* Temporomandibular joint function (opening, pain, limitations)
* Cricoarytenoid involvement (voice changes, stridor, dysphagia)
* Functional capacity (METs assessment, ADLs, mobility aids)

**Medication history**:

* Current immunosuppressive regimen (specific agents, doses, duration)
* Steroid use (dose, duration, previous stress dosing requirements)
* Disease-modifying agents (DMARDs, biologics, small molecules)
* Pain management (NSAIDs, opioids, adjuncts)
* Previous anaesthetic experiences and complications

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<summary>Outline your examination, highlight the findings you are expecting.</summary>

**Systematic examination**:

* **Airway**: Mallampati score, TMJ mobility, neck ROM, cervical stability
* **Respiratory**: Breath sounds, signs of ILD/pleural effusion
* **Cardiovascular**: Murmurs (valvulitis), pericardial rub, peripheral pulses
* **Musculoskeletal**: Hand/wrist deformities (IV access implications), spine assessment
* **Neurological**: Myelopathy signs, peripheral neuropathy

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<summary>She reports neck stiffness. How would you evaluate for atlantoaxial instability?"</summary>

**Clinical evaluation**:

* History of neurological symptoms (paresthesia, weakness, incontinence)
* Pain patterns (occipital/suboccipital pain, radiating to shoulders)
* Examine for myelopathy signs (Hoffman's, hyperreflexia, clonus)
* Lhermitte's sign (electric shock with neck flexion)
* Cranial nerve examination (particularly IX-XII)

**Imaging assessment**:

* Flexion/extension lateral cervical X-rays (anterior atlantodental interval >3mm)
* Review any previous MRI if neurological symptoms present (cord compression, pannus formation)
* CT for bony detail if surgical intervention being considered
* Review most recent imaging (changes over time)

**Anaesthetic implications**:

* Avoid neck manipulation, particularly hyperextension
* Plan for manual in-line stabilization during intubation
* Consider video laryngoscopy as primary approach
* Awake fiberoptic intubation if severe instability with neurological signs
* Document neck mobility limitations clearly

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<summary>Her medications include prednisolone 10mg daily, methotrexate, and infliximab. What are your concerns?</summary>

**Steroid considerations**:

* Long-term use (>7.5mg daily for >3 weeks) causes HPA axis suppression
* Risk of perioperative adrenal crisis without stress dosing
* Associated comorbidities: osteoporosis, poor wound healing, hyperglycemia
* Need for perioperative stress-dose steroid protocol

**Methotrexate management**:

* Hepatotoxicity potential (check LFTs)
* Myelosuppression risk (recent FBC, particularly WCC and platelets)
* Continue perioperatively per current guidelines (ANZCA, BSR recommendations)
* Drug interactions with NSAIDs (↑ methotrexate levels)

**Infliximab (anti-TNF) issues**:

* Increased infection risk (particularly respiratory)
* Timing of last dose and half-life considerations
* Impaired wound healing potential
* Potential for masking early sepsis signs (reduced inflammatory response)
* Check for TB screening prior to initiation

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<summary>She reports shortness of breath climbing one flight of stairs. How would you evaluate this?</summary>

**Differential diagnosis**:

* RA-associated pulmonary disease:&#x20;
  * Interstitial lung disease (most common)&#x20;
  * Pleural effusion/thickening
  * Bronchiolitis&#x20;
  * Pulmonary nodules
* Cardiac involvement (pericarditis, myocarditis, valvular disease)
* Anaemia (chronic disease and/or menorrhagia)
* Deconditioning from reduced mobility
* Drug-induced (methotrexate pneumonitis)

- **Targeted investigations**:
  * Baseline: CXR, spirometry, ECG, arterial blood gas
  * Advanced: DLCO (diffusion capacity), 6-minute walk test
  * HRCT chest if ILD suspected
  * Echocardiogram for cardiac evaluation
  * Complete blood count with iron studies
  * BNP if heart failure suspected
- **Risk stratification**:
  * Quantify functional capacity (METs)
  * Assess for supplemental oxygen requirement
  * Consider respiratory medicine consultation
  * Optimize pulmonary function preoperatively

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<summary>The surgeon anticipates significant bleeding. What preparations would you make?</summary>

**Preoperative preparation**:

* Full blood count with platelets
* Coagulation profile including fibrinogen
* Group and save (consider crossmatch 2 units)
* Iron studies and optimisation if anaemic
* Consider postponing if platelets <80 or significant coagulopathy or transfer to a location with increased transfusion capabilities

**Intraoperative strategy**:

* Two large-bore IV access (16G minimum)
* Consider arterial line for beat-to-beat BP monitoring
* Tranexamic acid 1g IV at induction
* Cell salvage setup if available
* Point-of-care testing (Hb, coagulation) availability
* Blood warmer and fluid warmer preparation

**Blood conservation techniques**:

* Controlled hypotension if appropriate
* Careful positioning to reduce venous pressure
* Communication with surgical team about hemostasis
* Restrictive transfusion threshold (Hb <70g/L)
* Active warming to prevent hypothermia-induced coagulopathy

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<summary>Detail your peri-operative management plan for this patient's medications.</summary>

**Steroid management**:

* Continue baseline prednisolone (10mg) on morning of surgery
* Supplemental dosing: hydrocortisone 50mg IV at induction
* Intraoperative: hydrocortisone 50mg IV q8h
* Postoperative tapering: • Day 1: hydrocortisone 50mg IV/PO TDS • Day 2: hydrocortisone 25mg TDS • Day 3: return to usual prednisolone dose

**Immunomodulators**:

* **Methotrexate**:&#x20;
  * Continue weekly dosing without interruption&#x20;
  * Time surgical date ideally 2-3 days from last dose&#x20;
  * Monitor LFTs and FBC postoperatively&#x20;
  * Ensure folate supplementation maintained
* **Infliximab (anti-TNF)**:&#x20;
  * Document date of last infusion&#x20;
  * If within 2 weeks of surgery, monitor closely for infection
  * Restart postoperatively when wound healing established&#x20;
  * Coordinate with rheumatologist for optimal timing

- **Analgesics**:
  * Discontinue NSAIDs 5 days preoperatively
  * Multimodal non-NSAID regimen:&#x20;
    * Paracetamol scheduled
    * Regional anaesthesia when possible&#x20;
    * Short-acting opioids as needed
- **Perioperative additions**:
  * VTE prophylaxis (mechanical + chemical)
  * Stress ulcer prophylaxis (PPI)
  * Continuation of essential medications (antihypertensives, etc.)

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<summary>She takes regular ibuprofen 400mg TDS for joint pain. When would you stop it and why?</summary>

**Cessation timing**:

* Discontinue 5 days before surgery
* Resume no earlier than 24 hours post-op, guided by renal function and bleeding risk

**Rationale for discontinuation**:

* Reversible platelet dysfunction (inhibits thromboxane A2)
* Increased surgical bleeding risk (particularly problematic in laparoscopy)
* Potential interaction with methotrexate (increases methotrexate levels)
* Impaired renal function risk with surgical stress
* Potential interference with prostaglandin-mediated bone healing

**Alternative pain management**:

* Scheduled paracetamol 1g QID
* Low-dose tramadol if needed
* Topical NSAIDs for accessible joints
* Consider pregabalin 75mg BD for neuropathic component

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<summary>Her preoperative Hb is 95 g/L. How would you manage this?</summary>

**Further investigation**:

* Iron studies (ferritin, transferrin saturation, TIBC)
* B12 and folate levels
* Reticulocyte count
* Assess for occult bleeding (menorrhagia history, fecal occult blood)
* Consider inflammatory markers (ESR/CRP) to assess disease activity

**Treatment approach**:

* If iron deficient: IV iron (ferric carboxymaltose 1000mg)
* If functional iron deficiency: EPO 40,000 units weekly + IV iron
* Timeline assessment: ideally treat 3-4 weeks before surgery
* Patient Blood Management principles:&#x20;
  * Single Hb trigger insufficient for transfusion decision&#x20;
  * Consider symptoms, comorbidities, expected blood loss

**Intraoperative considerations**:

* Cell salvage unavailable
* Tranexamic acid administration
* Restrictive transfusion threshold (Hb <70g/L if asymptomatic)
* Monitor for signs of tissue hypoxia (lactate, base deficit)

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<summary>Postoperatively she becomes hypotensive (BP 85/40). What's your approach?</summary>

**Immediate assessment**:

* Full vital signs including temperature
* Clinical examination (bleeding, capillary refill, urine output)
* Assess fluid status (JVP, lung auscultation)
* Check surgical drain output
* Review recent medications

**Differential diagnosis**:

* Hypovolemia:&#x20;
  * Surgical bleeding (most common)&#x20;
  * Inadequate fluid replacement
* Adrenal crisis (missed steroid supplementation)
* Anaphylaxis (late presentation)
* Sepsis (immunocompromised status increases risk)
* Cardiac event (RA patients have increased CV risk)
* Pulmonary embolism

**Initial management**:

* Fluid challenge (250-500ml crystalloid)
* Hydrocortisone 100mg IV if adrenal crisis suspected
* Urgent Hb check (point-of-care)
* Surgical team review
* Vasopressors if no response to initial measures

**Further investigations**:

* Arterial blood gas (lactate, base deficit)
* 12-lead ECG
* Urgent FBC, coagulation studies
* Blood cultures if temperature >38°C
* Consider CT if PE suspected

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<summary>The surgeon wants to delay restarting infliximab for 6 weeks. What's your advice?</summary>

**Evidence-based guidance**:

* ACR/BSR guidelines suggest restarting when wound healing established
* Typical delay: 10-14 days post-surgery if uncomplicated
* Six weeks is excessive and risks disease flare

**Risk assessment**:

* **Infection risks** with early restart:&#x20;
  * Wound complications&#x20;
  * Delayed healing&#x20;
  * Masked sepsis symptoms
* **Disease flare risks** with prolonged withholding:&#x20;
  * Increased joint damage&#x20;
  * Steroid requirement increase&#x20;
  * Pain management challenges&#x20;
  * Reduced mobility and rehabilitation

- **Recommended approach**:
  * Individualised decision with rheumatologist input
  * Assess wound healing at 2 weeks post-op
  * Resume when surgical site shows good healing (typically 2-3 weeks)
  * Monitor closely for infection signs after restarting
  * Consider bridging with prednisolone increase if symptoms worsen

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<summary>What specific risks does this RA patient face during positioning for laparoscopic hysterectomy?</summary>

**Cervical spine risks**:

* Atlantoaxial instability during positioning
* Risk of cord compression with hyperextension
* Exacerbation of pre-existing myelopathy
* Need for neutral neck position with manual stabilization

**Joint-specific concerns**:

* Potential for joint subluxation with manipulation
* Limited ROM causing positioning challenges
* Deformities creating pressure points (ulnar deviation, swan neck)
* Fixed flexion contractures limiting positioning options

**Trendelenburg position challenges**:

* Respiratory compromise (reduced FRC, already restricted lungs)
* Increased intracranial pressure with cervical spine disease
* Difficult IV access maintenance with hand deformities
* Shoulder braces potentially damaging vulnerable joints
* Lithotomy component stressing hip/knee joints

**Pressure injury risks**:

* Reduced tissue padding over bony prominences
* Steroid-induced skin fragility
* Peripheral neuropathy reducing sensation
* Longer positioning time due to technical challenges

**Preventive measures**:

* Pre-positioning joint assessment
* Additional padding at pressure points
* Careful documentation of pre-existing limitations
* Regular position checks during lengthy procedures
* Consider pressure-reducing mattress

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<summary>She develops bronchospasm during pneumoperitoneum establishment. How would you manage this?</summary>

**Immediate actions** (0-2 minutes):

* Inform surgical team and request temporary procedure pause
* Increase FiO₂ to 100%
* Deepen anesthesia (propofol bolus 0.5mg/kg)
* Manual ventilation to assess compliance and confirm diagnosis
* Auscultate to confirm wheeze pattern/distribution

**Differential diagnosis**:

* Anaphylaxis (check for other signs: rash, hypotension)
* ETT malposition (endobronchial/kinked)
* Aspiration
* Pneumothorax (particularly with high airway pressures)
* Pulmonary edema
* True bronchospasm (RA-associated bronchiolitis)

**Pharmacological management**:

* Salbutamol 8-10 puffs via circuit MDI adaptor
* IV salbutamol 250μg slow bolus if severe
* Magnesium sulfate 50mg/kg if persistent
* Hydrocortisone 100mg IV (already part of steroid protocol)
* Consider ketamine 10-20mg if refractory

**Ventilation adjustments**:

* Increase I:E ratio (1:3 or 1:4)
* Reduce respiratory rate
* Accept permissive hypercapnia
* Consider requesting reduced pneumoperitoneum pressure

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<summary>How would you prevent and monitor for intraoperative awareness in this patient?</summary>

**Risk assessment**:

* RA patients may have altered pharmacokinetics
* Cardiovascular instability may limit anesthetic depth
* Polypharmacy may affect drug metabolism
* Trendelenburg position affects drug distribution

**Preventive measures**:

* Adequate pre-medication (anxiolysis)
* Sufficient induction dose accounting for cardiac status
* Maintain age-adjusted MAC >0.7-0.8
* Avoid unnecessary neuromuscular blockade
* Anticipate reduced anesthetic requirements with age
* Maintain normothermia (affects drug metabolism)

**Monitoring approaches**:

* Processed EEG monitoring (BIS target 40-60)
* End-tidal anesthetic gas monitoring
* Clinical signs: autonomic responses
* Consider isolated forearm technique if high risk
* AEP monitoring if available for difficult cases

**Documentation and follow-up**:

* Detailed anesthetic record of all agents
* Record of any periods of light anesthesia
* Post-operative interview using Brice questions
* Clear explanation of monitoring used to patient

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<summary>Post-op she complains of right arm numbness. What's your approach?</summary>

**Immediate assessment**:

* Specific distribution pattern (dermatome/peripheral nerve)
* Motor vs. sensory predominance
* Temporality (immediate vs. delayed)
* Pre-existing symptoms vs. new onset
* Associated pain characteristics

**Focused examination**:

* Motor testing (specific muscle groups)
* Sensory testing (light touch, pinprick, proprioception)
* Reflexes (particularly biceps, triceps)
* Vascular assessment (pulses, capillary refill)
* Comparison with contralateral side and baseline function

**Likely causes in RA patient**:

* Positioning-related:&#x20;
  * Brachial plexus traction (especially with shoulder braces)&#x20;
  * Ulnar nerve compression at elbow&#x20;
  * Radial nerve compression against arm board
* Disease-related:&#x20;
  * Exacerbation of pre-existing neuropathy&#x20;
  * Cervical radiculopathy triggered by positioning&#x20;
  * Rheumatoid vasculitis affecting vasa nervorum

- **Management plan**:
  * Documentation of findings
  * Distinguish surgical vs. anesthetic etiology
  * Early neurology referral if significant motor involvement
  * Expected timeframe for resolution (4-6 weeks typically)
  * Physiotherapy referral
  * EMG/NCS after 3-4 weeks if persistent

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<summary>The surgeon requests deeper neuromuscular blockade for better surgical exposure. How would you respond?</summary>

**RA-specific considerations**:

* Potential increased sensitivity to NMBs
* Disease-associated myopathy risk
* Steroid-induced myopathy
* Drug interactions with immunosuppressants

**Assessment before deepening blockade**:

* Current surgical conditions (actual need vs. preference)
* Patient factors (respiratory status, anticipated emergence)
* Available monitoring (quantitative TOF)
* Reversal agent availability

**Implementation approach**:

* Quantitative neuromuscular monitoring mandatory
* Rocuronium preferred (reliable reversal with sugammadex)
* Titrate to PTC 1-2 for deep block
* Avoid bolus doses (incremental titration)
* Consider alternative approaches:&#x20;
  * Increase pneumoperitoneum pressure slightly&#x20;
  * Deepen anesthesia temporarily&#x20;
  * Optimise patient position

- **Reversal planning**:
  * Calculate appropriate sugammadex dose (4mg/kg for deep block)
  * Ensure availability before administering additional NMBA
  * Plan for potential prolonged emergence
  * Document TOF ratio >0.9 before extubation

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