PIG Meeting: 13th May 2021
72yo male with subacute RUQ pain for ERCP and trans-cystic stent
- Right heart failure with severe TR and dilated RV.
- Anaemia (Hb76) due to non-healing telangiectasia in the small bowel. Rpt Fe infusions. On EPO.
- Antibodies in blood therefore cross-matching extremely difficult/impossible.
- BMI 38
- OSA on CPAP
- NIDDM (controlled)
- Difficult intubation
- Episode of non-sustained VT during ERCP last year.
- RUQ pain
- ? Due to liver capsule stretch v. Biliary colic
- Severe, causing reduced QoL
- Severe RHF
- Exacerbated by non-adherence to diuretics due to difficulties with frequent urination
- Under a general physician who suggests patient is ‘as good as he gets’ (when adherent)
- Should the procedure go ahead?
- Complicated. Likelihood of benefit uncertain.
- ? Warrants a period of high adherence to diuretics to see if pain resolves
- PO diuretics may be poorly absorbed in severe RHF so ? IV in-patient trial warranted
- Discussed further with physician – PO adequate, improved with adherence ++
- QoL choice for the patient, with their values taken strongly into consideration, as this patient is essentially palliative.
- Anaesthetic technique?
- PPV likely helpful physiologically in RHF. Hypercapnoea, hypoxia and subsequent increased PVR all poorly tolerated, so a controlled GA likely safest technique.
- GA also avoids rapid need to manage known difficult airway in a prone, complex patient.
- Patient recently had specialised endoscopic procedure (elsewhere) to evaluate his telangiectasia – plan to r/v those anaesthetic notes.
- If so, where should the procedure take place?
- Endoscopy suite easier/faster for the proceduralist – has merit.
- Endoscopy suite = distant from help.
- Suggested that with pre-arranged additional skilled help (anaesthetic nurse and doctors) endoscopy suite likely ideal.
- Further optimisation possible?
- Low risk of bleeding. Anaemia on maximal therapy regardless.
- See above for comments from physician.