52yo Aboriginal man. Referred to DA for Opinion- suitability for laparoscopic cholecystectomy or cholecystostomy.
Admitted to hospital with Chest pain, dyspnoea, and hypotension. Negative Troponin and CTPA. CT demonstrated calculous cholecystitis. Biliary sepsis with E-coli in biliary fluid.
- IDDM – on SGLT2 inhibitor
- AF with slow ventricular response
- PPM in 2013, 99% paced
- Obese ~110kg
- Living alone, independent ADL
Acute decompensation of chronic RV impairment during admission
- Worsening orthopnoea and dyspnoea, NYHA II->III
- Working diagnosis: sepsis-induced decompensation
- Echo – LV ok, MV/AV normal. RV- mod dilation, mildly D-shaped, Pressure and Volume overloaded. PAP peak 62mmHg. Hepatic vein flow reversal.
- CT- fibrosis and traction bronchiectasis.
- Decision made to proceed to Cholecystostomy via interventional radiology
Development of new Biventricular failure
- INR was noted to be 1.5 in setting of rivaroxaban therapy for AF
- Xa level normal
- Decision in conjunction with haematology to give 4 units of FFP
- Developed hypoxia and biventricular failure, requiring BiPAP
Worsening of Glycaemic control
- Interruption to usual therapy
Discussion and Plan:
Timing and preparation for laparoscopic cholecystectomy
- Distance patient
- Plan is to be discharged with cholecystostomy tube in-situ
- Ideally patient shouldn’t have to travel to Newcastle multiple times
- Refer to regular cardiologist for review and repeat echocardiogram preoperatively
- Endocrine review – rapid access endocrine clinic offers telehealth
- Difficult situation to navigate as driven by procedural team and appropriately consulted with haematology
- Prothrombinex may have been a superior choice in this situation due to less volume and increased effectiveness
- Regular anaesthetic list in interventional radiology, it may be useful to have a combined meeting/CME in order to gain mutual knowledge on the procedures and perioperative preparation
- Interventional radiology society guidelines on periprocedural anticoagulants discussed; https://irsa.com.au/consensus-guidelines-on-anticoagulants-in-ir/