Month July 2021

Endoscopies and pleural effusion

garychleung

PIG Meeting: 24th June 2021

72yo male for gastroscopy and colonoscopy due to upper GIH and obstructive colonic symptoms

Background:

  • Presumed sarcoidosis (hasn’t attended F/U) with mediastinal adenopathy
  • ? metastatic lung malignancy. Previous effusion (? parapneumonic) drainage showed no malignant cells. Effusion now recurred. Nodules in lungs stable on repeat CT.
  • Severe cardiac disease
    • TTE 2021 (in context of admission for anaemia) Severely dilated left ventricle with severe RWMAs. EF 26%. Moderately dilated right ventricle with moderate systolic dysfunction. Moderate AS and AR. Mild to moderate MR. Moderately dilated atria. 
    • IHD – AMI ’09, PCI
  • PHTN – mod/severe at rest. 
  • TIA 2018
  • CKD
  • Ex-smoker

Issues:

  • SOBOE
    • Recent exercise tolerance reduction. Gentle incline, 100m, multiple breaks for SOB.
    • Orthopnoea.
    • ? malignancy
    • ? cardiac component to dyspnoea
  • Patient psychosocial issues
    • Difficult historian
    • DNA for multiple appointments and investigations previously
    • Patient declined face-to-face review in clinic
    • Surgical team unaware of multiple other complex issues

Discussion

  • Fit for endoscopies?
    • Greater issue is the benefit from these procedures. Diagnostic rather than therapeutic.
    • Surgical team has highlighted that if metastatic lung disease present, endoscopies may not need to occur
  • Optimisable?
    • Difficult to know from history alone.
    • Requires face to face review

Plan:

  • Admit for TTE (as unable to secure timely booking pre-admission)
  • Respiratory team will review while inpatient
  • Pending these reviews and pleural fluid drainage, endoscopies may proceed
  • Requires inpatient admission for bowel prep regardless due to multiple severe comorbidities

HBV in pregnancy, for elective Caesarean Section

garychleung

PIG Meeting: 24th June 2021

33yo female for repeat CS

Background:

  • HBV – reactivated during pregnancy. Risk of vertical transmission
  • Albumin 30
  • Ferritin 45
  • Hb and platelet normal. 

Discussion

  • Implications of HBV in pregnancy
    • Not uncommon for reactivation due to immunosuppressive state of pregnancy
    • As per RANZCOG:
      • Method of delivery shouldn’t be affected by HBV status
      • Invasive procedures which may breech the maternal/foetal blood barrier should be avoided (e.g., foetal scalp clip)
      • Breast feeding is not contraindicated provided appropriate immunoprophylaxis has been given at birth.
      • With high viral load in third trimester, appropriate to commence antiviral therapy to reduce risk of transmission to baby
      • Arrangements for passive (HBIG) and active immunisation of baby need to be in place.
  • HBV testing
    • Noted that titres are reported in log multiples, therefore increasing levels represent exponential increase.
  • Universal precautions should be used. Patient will still have high HBV titres and therefore high infectivity at time of CS.

Elderly male, consultation for consideration of EVAR

garychleung

PIG Meeting: 24th June 2021

83yo male with a 6.7cm aortic aneurysm. 

Background:

  • CAD
  • CABG + MVR 2009 – on warfarin
  • CCF EF 19%
  • COPD on home O2, ex-smoker
  • Severe Pulmonary HTN
  • Last TTE May 2021 – mildly dilated LV with severe global systolic dysfunction, severely dilated LA (volume 53mls/m2), well-seated mechanical mitral valve, severe pulmonary HTN (PASP 68), moderate TR, mild AR, EF 19%

Issues

  • Current inpatient with CCF exacerbation
  • Recent reduction in exercise tolerance
  • Referred to ED from perioperative clinic with SpO2 80% after 20m walk. NYHA class 4 dyspnoea.

Discussion

  • Should surgery proceed?
    • Life expectancy? Is he likely to die from his aneurysm or his cardiorespiratory comorbidities first (rupture rate for 6.7cm AAA is ~ 20% per year)
    • EVAR is a low physiologic stress procedure. 
    • Need clear documentation of ceilings of care (i.e., not for open procedure in emergency or if complications from EVAR)
  • Anaesthetic technique
    • GA may facilitate faster procedure and less IV contrast use (protecting from renal injury) due to improved immobility.
    • Can be done under LA/sedation if patient can lie flat/still and cooperate with breath holds

Plan:

  • Await outcome of current admission and liaise with surgical team (who are aware of admission)