Acute cholecystitis and RHF

Gabrielle Morris

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.

Background:

  • IDDM – on SGLT2 inhibitor
  • AF with slow ventricular response
  • PPM in 2013,  99% paced
  • Obese ~110kg
  • Living alone, independent ADL
  • Ex-smoker

Issues:

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

  • Sepsis
  • 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

INR Reversal

  • 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/