Heart Stopping Stuff!

1. Dr Deirdre Hussey Heart Stopping Stuff!

2. Mr SW 82yrs 18 month hx of intermittent crampy right sided abdo pain Localised to RIF in last 5/7 Constant and severe Associated loose stool x 8/12 (3 loose stool/day) No assoc nausea or vomiting Assoc 5kg weight loss in last year

3. Mr SW • CVA 2003 • IDDM • Hypertension • Laparotomy for SBO 2005 • Open cholecystectomy 35 yrs ago

4. SW Meds: Keppra Aricept Galfer Tritace Istin Lipitor NKDA Nil FHx of note Ex smoker No C2H5OH Married, 4 children

5. BP 150/65 HR 90 bpm regular Temp 37.1 Sats 96% on RA Dehydrated Clutching R side of abdomen on moving CVS exam unremarkable Respiratory: mildly decreased breath sounds on RLL. Nil else. SW

6. SW • Abdomen moderately distended • Guarding and Rebound tenderness in RIF • Could not tolerate deep palpation • Palpable mass in RIF approx 3-4cm in size • Bowel sounds audible, normal in character • PR exam- loose stool, FOB negative, no masses

7. Hb 10.6 WCC 10.89 Neut 9.09 Plts 191 ESR 65 CRP 185 BIli 12 Alt 31 Alk Phos 120 Urea 11.3 Na 136 K 4.2 Creat 138 Chlor 105 INR 1.19 Glu 6.2 SW

8. SW • Erect Chest Xray- No free air, NAD • PFA- mildly dilated large bowel loops, small bowel NAD • Initial management-fluids, analgesia, catheter

9. Differential Diagnosis • ? Appendictis • ? Caecal malignancy • Right sided diverticulitis

10. SW “Appendicular Abscess in right iliac fossa. 4.63cm in diameter”

11. SW • Suspected appendicular mass • Probable abscess measuring 4.63cm in diameter • No evidence of intra-abdominal lymphadenopathy • Incidental left renal cyst

12. Options

13. Conservative Management

14. Operative Intervention

15. Options? • Drainage? – not accessible; perforation and > 4cm abscess • Antibiotics/Conservative? – symptomatic, obvious perforation, most likely appendix • Theatre? Definitive diagnosis and management

16. SW Taken to theatre for laparoscopy +/- proceed Balloon port inserted and pneumoperitoneum created.. Moments later before visualisation of abdomen obtained………..

17. SW • Rapid Anaesthetic intervention, atropine… To Proceed or Not to Proceed, that is the question ?

18. SW • Paramedian laparotomy • Findings: • Perforated appendix and associated abscess cavity • Free pus in RIF • Large inflammatory mass extending to caecum • No tumour palpated

19. SW • Currently recovering on ward • Post operative Atrial fibrillation • Planned for discharge early next week

20. Points of Interest • Acute appendicitis in the elderly; diagnostic and management challenges • Asystole and bradycardia associated with pneumoperitoneum at laparoscopy

21. Appendicitis Affects 7% of population Mortality rate 0.8%-8% Mortality rate 20% in patients >70 yrs (diagnostic delay) Perforation rates higher in <18yrs and >50 years ‘Classical history’ in 50% cases only

22. Appendicitis in the Elderly Delayed presentation of AA in elderly as result of diminished inflammatory response Psychosocial delay Co-morbidities confuse diagnosis Higher perforation rates Five times greater mortality rate

23. A 10-year retrospective review found that the diagnosis was delayed in 35% of patients (Lee, 2000). Again, a high index of suspicion is necessary to avoid missing this diagnosis • Aust NZJ Surg. 2000;70(8):593-6

24. Principles remain the same – operative intervention is best curative option Prompt diagnosis and intervention improves outcome wrt morbidity and mortality Arch Surg 137 ; 2002 Lap vs Open in elderly – Shorter length of stay Higher rate of routine discharge Lower morbidity and mortality rates Surgery 135:5 479-488 2004 less post op pain Surg Endosc 26:6;212-215: 2006 Discussion - Management

25. Under Pressure

26. Asystolic Arrest at Laparoscopy • Asystolic cardiac arrest: a rare complication of laparoscopy. Shifren JL, Adlestein L, Finkler NJ. • Obstet Gynecol. 1992 May;79(5 ( Pt 2)):840-1 • Asystolic Cardiac Arrest during laparoscopic cholecystecomy • Biswas TK, Pembroke A. • Anaesth Intensive Care. 1994 Jun;22(3):289-91. No abstract available. • Recurrent asystolic cardiac arrest and laparoscopic cholecystectomy: a case report and review of the literature • Valentin MD, Tulsyan N, Dolgin C. • JSLS. 2004 Jan-Mar;8(1):65-8. Review • Asystolic cardiac arrest during balloon insufflation for endoscopic extraperitoneal radical prostatectomy • Hoda MR, Freodrichs M, Kummel C, Nitzke T,Pooken • J Endourol. 2009 Feb;23(2):329-31

27. Insufflation Pressure • Routine low-pressure pneumoperitoneum during laparoscopic cholecystectomy • D.  Davides1, K.  Birbas1, A.  Vezakis1 and M. J.  McMahon1 Surgical Endoscopy 13:9;1999 • LC can be performed routinely at low intraabdominal pressure, which may contribute to the safety and comfort of the procedure. • Randomized trial of different insufflation pressures for laparoscopic cholecystectomy • D. H. Wallace 1, M. G. Serpell 2, J. N. Baxter 1, Mr P. J. O'Dwyer BJS: 84:4, Pages 455 - 458 • Insufflation pressure significantly affects the haemodynamic changes and postoperative pain associated with laparoscopic cholecystectomy.

28. E.A.E.S. Clinical Practice Guideline on the Pneumoperitoneum for Laparoscopic Surgery • Choice of insufflation pressure • The panel recommends to use the lowest intraabdominal pressure allowing adequate exposure of the operative field, rather than using a routine pressure • An intraabdominal pressure lower than 14 mmHg is considered safe in a healthy patient • Abdominal wall lifting devices have no clinically relevant advantages compared to low-pressure (5-7 mmHg) pneumoperitoneum

29. Conclusion • Atypical presentation of appendicitis in the elderly • Close monitoring of vital signs on creation of pneumoperitoneum – engage attention of anaesthetist • Consider using lower insufflation pressures