42yo lady for Gastroscopy/colonoscopy/ polypectomy

Background:

• Congenital heart disease – single ventricle
  • pulmonary stenosis 
  • moderate pulmonary hypertension 
  • No cardiac surgery
  • Yearly cardiology review and echocardiogram
  • SpO2 70% in clinic – usual range 70-80% for patient
• Polycythemia
• Living independently, working. Goes to gym

Issues: 

• Palpitations – increasing over last few years.
  • Extensive cardiac investigations
  • Atrial ectopics – no intervention required.
  • Reports of increased palpitations recently – no syncope or associated symptoms
• Anxiety – significant around awareness of palpitations.
  • Seeing psychologist
• Functional capacity – 
  • Limited by NYHA class 2 dyspnoea 
  • DASI scored 18.7, Mets 5 
  • Discussion around accuracy of self-filling form as opposed to clinician questioning
• Positive FOBT in setting of melaena 
  • Strong FHx bowel cancer – sister Passed 1yr ago
  • Strong indication for testing
• Annual cardiology review due day after procedure 

Discussion:

Update from cardiologist:

• Patient has previously refused surgery for CHD and refuses all meds
• Appropriate to proceed to endoscopy.
• Tolerance of hypoxia advised during anaesthetic as not correctable

Anaesthetic techniques

• GA v. awake. 
• Patient expectation management key
• Would a cardiac anaesthetist have additional skills to offer if more major surgery required (e.g. bowel resection)? Unclear, for further discussion should the need arise.
• Should surgery be undertaken at PHTN centre (Pulmonary Hypertension Australia website lists RPA and St Vincent’s as PHTN centres). How does this differ from our service at JHH with a PHTN MDT?

Bowel prep plans

• Patient cognitively and mobility-wise able to manage bowel prep at home.

Plan:

• Proceed
• Bowel prep at home.
• Anaesthetist needs notification/call regarding case
• Cardiology Interest meeting – clarify PHTN centre v. JHH differences