Negative predictive value of dobutamine stress echocardiography for perioperative risk stratification in patients with cardiac risk factors and reduced exercise capacity undergoing non-cardiac surgery.

BACKGROUND: Guidelines recommend functional testing for myocardial ischaemia in the perioperative setting in patients with greater than one recognised cardiac risk factor and self-reported reduced exercise capacity. AIM: To determine the clinical utility of dobutamine stress echocardiography (DSE) for perioperative risk stratification in patients undergoing major non-cardiac surgery. METHODS: Data on 79 consecutive patients undergoing DSE for perioperative risk stratification at a single centre were retrospectively reviewed to determine rates of major adverse cardiac events (MACE) during the index hospitalisation and 30 days post-discharge. Echocardiography and outcome data were obtained through a folder audit and echolab database. RESULTS: Out of the 79 DSE performed for perioperative risk stratification, 11 (14%) were positive (DSE +ve) and 68 (86%) were negative (DSE -ve). Management in the DSE +ve group included medical optimisation without invasive intervention (n = 7(64%)), diagnostic coronary angiography (n = 3(27%)) and coronary artery bypass graft (n = 1(9%)). None of the patients underwent percutaneous coronary intervention preoperatively. Perioperative MACE in the DSE +ve group was 36% compared to 4% in the DSE-ve group (P = 0.006). DSE +ve was a powerful predictor of perioperative inpatient MACE (OR 12.4, 95% CI 2.3-67, P = 0.003). The positive predictive value of DSE +ve status was 36%, whereas the negative predictive value of DSE-ve status for perioperative MACE was 96%. CONCLUSION: DSE for perioperative risk stratification had a high clinical utility in patients undergoing major non-cardiac surgery. In particular, a normal DSE had a high negative predictive value for perioperative MACE.

Role of telehealth in perioperative medicine for regional and rural patients in Queensland.

BACKGROUND: Australians living in regional, rural and remote areas face a myriad of complexities resulting in a trend to poorer health outcomes. Telehealth is being utilised as an alternative mode of service delivery to overcome such barriers. However, there is limited published information concerning the use of telehealth in perioperative medicine. AIMS: To review the performance of the telehealth preoperative assessment service at Mater Hospital Brisbane to determine last-minute cancellation rates secondary to medical reasons. METHODS: A retrospective chart audit of all patients referred to perioperative medicine telehealth consultation services was provided at Mater Hospital Brisbane. RESULTS: During a 1-year period, 229 patients across eight surgical subspecialties were referred for telehealth assessment (85 females, 144 males) with a median age of 67 years. Patients lived a median distance of 1597 km from Brisbane. Of the 229 patients included in the study, 7 (3.1%) experienced last-minute cancellations. From these data, the last-minute cancellation rate due to medical reasons was 1.3%, which is consistent with the international average. CONCLUSION: The Mater Hospital Perioperative Medicine Telehealth Programme is a means of providing comprehensive perioperative assessment to regional, rural and remote patients that result in reduced last-minute surgical cancellations and surgery within or below the national recommended guidelines.

Adult-onset Pompe's disease presenting with insidious hypercapnic respiratory failure.

Orthopnoea is commonly attributed to heart failure but can be caused by diaphragm weakness, which, when severe, is often associated with hypercapnic respiratory failure. Bilateral diaphragm weakness is generally due to systemic nerve or muscle disease and usually occurs in the setting of severe generalized muscle weakness, but the diaphragm can be the initial or only muscle involved. Here, we report the case of a 39-year-old female who presented with slowly progressive orthopnoea and daytime somnolence. Pulmonary function studies and polysomnogram confirmed bilateral diaphragm weakness complicated by nocturnal hypoventilation and she was subsequently diagnosed with adult-onset Pompe's disease, a rare metabolic myopathy.