Severe RHF and possible biliary colic

garychleung

PIG Meeting: 13th May 2021

72yo male with subacute RUQ pain for ERCP and trans-cystic stent

Background

  • 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)
  • HTN
  • Difficult intubation
  • Episode of non-sustained VT  during ERCP last year.

Issues

  • 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)

Discussion

  • 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.