PIG Meeting: 4th March 2021
73yo male booked for lap chole due to recurrent choledocholithiasis
- Choledocholithiasis – several admissions with sepsis requiring IV Abx and ERCPs
- Cardiac disease
- Missed STEMI 2019 – DES to LAD, LCx occluded, not amenable to PCI
- Polymorphic VT arrest 2019 2 days post ERCP, hypokalaemic.
- 2nd polymorphic VT arrest 2/7 later (K+ normal)
- AICD placed, nil shocks since.
- Bisoprolol and amiodarone
- Paroxysmal AF – on dabigatran
- Ex tolerance 5 METS as per DASI
- Cardiac status
- TTE – EF 30-35%, stage I diastolic dysfx, mild MR, mild AR, e/o inferolateral RWMAs, biatrial moderate to severe enlargement.
- Reviewed by cardiologist – Nil current e/o CCF, exercise tolerance only mildly limited
- Should he have surgery?
- SORT score 5.4% risk of death
- Severe cholangitis in this man carries a high risk of morbidity and mortality, as does emergency surgery.
- While his risk of death with elective surgery is not insignificant it is likely the lower risk option.
- Opportunities for optimisation?
- Cardiologist r/v suggests HF reasonably controlled. Suggested ceasing Dabigatran 48h preop and switching to aspirin until resumption of anticoagulation.
- Postoperative care location
- >5% risk of perioperative mortality widely considered to represent ‘high risk’ however limited ICU bed spaces necessitates thoughtful rationing of resources.
- Extended recovery (i.e. 4hr stay) is a useful option – observe for dysrythymias, replenish electrolytes as needed, support normal physiology then, provided no issues arise, discharge to normal ward.