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Obstructive Jaundice – Whipple’s Operation Anesthetic Management. Munisha Agarwal Professor Deptt. of Anaesthesiology & Intensive Care L N Hospital & Maulana Azad Medical College Delhi. www.anaesthesia.co.in [email protected] Obstructive Jaundice.

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Obstructive jaundice whipple s operation anesthetic management

Obstructive Jaundice – Whipple’s OperationAnesthetic Management

Munisha Agarwal

Professor

Deptt. of Anaesthesiology

& Intensive Care

L N Hospital & Maulana

Azad Medical College Delhi

Obs. J

[email protected]


Obstructive jaundice

Obstructive Jaundice

Physiological functions of Liver ?

Obs. J


Physiological functions of liver
Physiological functions of Liver

  • Glucose Homeostasis

  • Fat Metabolism

  • Protein Synthesis

  • Drug & Hormone Metabolism

  • Bilirubin formation &excretion

  • Anti bacterial action

  • Blood Reservoir

Obst. J


Glucose homeostasis
Glucose homeostasis

Glucose hepatocytes glycogen glucose

lactate

glycerol

AA

Obst. J


Glucose homeostasis1
Glucose Homeostasis

  • Glycogen stores 75gm 24—48hrs

  • Anesthesia – gluconeogenesis

  • Provide ext. source of glucose

Obst. J


Fat metabolism
Fat metabolism

  • Synthesis of lipo-proteins & cholesterol

  • Oxidation of FA to ketone bodies

Obst. J


Protein metabolism
Protein Metabolism

  • Deamination of AA

  • Formation of urea

  • Plasma proteins

    - All except y globulin & factor VIII

    - Albumin daily prod. 10—15g/d (3.5-5.5gm%)

    - liver disease  alb  glob

    Albumin ?

Obst. J


Protein synthesis
Protein synthesis

  • Plasma O. P.

  • Drug binding

  • Coagulation

  • Hydrolysis

Obst. J


Drug binding
Drug binding

  • Drugs reversibly combine with Albumin

  •  albumin  binding sites  free drug

  • Albumin < 2.5gm%

  • Acute Hepatic dysfunction ?

    Coagulation ?

Obst. J


Drug binding1
Drug binding

  • Acute hepatic dysfunction - drug binding not affected

  • T ½ Albumin : 14 – 21 days

  • Coagulation : affected (2—6hrs)

  • Vitamin K dependent Coag. Factors?

Obst. J


Coagulation
Coagulation

  • Prothrombin, fibrinogen

  • Factor V, VII, IX, X ( except VIII)

    Deranged Coagulation ?

Obst. J


Coagulation1
Coagulation

Deranged coagulation

  • ed synthesis of Clotting factors

  • ed PT Vit. K deficiency d/t biliary obstruction absence of bile salts

  • Thrombocytopenia

  • ed Fibrinolysins

Obst. J


Coagulation2
Coagulation

  • Evaluate PT/ PTTK/ BT

  • LFT grossly deranged before coagulation abnormalities appear

  • 20%--30% activity required for normal coagulation

  • T1/2 of clotting factors produced in liver is very short (in hrs)

  • Ac. Hep dysfunction  Coag. Abn.

Obst. J


Drug metabolism
Drug metabolism

- Lipophilic →water soluble, less reactive

Enzymatic reaction

phase I - oxidation (Cyt P450)

- reduction & hydrolysis (L.A)

phase II - conjugation, glucuronidation,

sulphation, methylation &

acetylation

- UDGT ( Bilirubin, morphine,

aminophylline)

Conjugation reaction?

Obst. J


Drug metabolism1
Drug metabolism

Clearance of drugs from plasma

High HE ratio ~ Hepatic Blood Flow (HBF) Lidocain, Pethidine, Fentanyl

low HE ratio ~microsomal enzymes

~protein binding

diazepam, thiop, pancuronium

Obst. J


Drug metabolism2
Drug metabolism

Anesthetic implications

  • Chronic liver disease  drug metabolism d/t - ed no. of hepatocytes

    - HBF

  • Repeated injection  cumulative effect

  • Volatile anesth. Agents  ed clearance of drugs

Obst. J


Bilirubin formation excretion
Bilirubin formation & excretion

  • Daily prod 250—350mg/d

  • Interpretation of plasma & urine bilirubin

  • Categories of liver dysfunction

    1 unit BT ?

Obst. J


Blood reservoir
Blood Reservoir

  • 10% of total blood volume

  • Available for Auto transfusion into central circulation

Obst. J


Hepatic blood supply
Hepatic Blood Supply

  • Unique ?

Obst. J


Hepatic blood supply1
Hepatic Blood Supply

  • 25% to 30% of CO

  • Dual supply

    Portal V (75%) 85% saturated

    Hepatic A (25%) 95%saturated

    2/3 of oxygen used by liver

Obst. J


Control of liver blood flow
Control of Liver Blood Flow

INTRINSIC

  • AUTOREGULATION

    - Hepatic artery-80 mmHg

    - Portal vein – flow from spleen, intestine

    - resistance to vascular bed

  • Hepatic Arterial Buffer response.

    Extrinsic ?

Obst. J


Control of liver blood flow extrinsic

Increase HBF

Acute hepatitis

Supine posture

Hypercapnia

Drugs

βadrenostimulation

Decrease HBF

Hypoxia

Hepatic cirrhosis

Upright posture

Hypocapnia/IPPV/PEEP

Drugs

βadrenoreceptor blockade/ α agonist

Ganglion blockade

Anaesthetic agent

Control of Liver Blood FlowEXTRINSIC

Obst. J


Liver function tests
Liver Function Tests

  • Non specific

  • Large hepatic reserve

    LFT ?

Obst. J


Liver function tests1
Liver Function Tests

  • S. Bilirubin (T) - 0.3—1.1mg%

    {(I) 0.2-0.7mg%, (D)0.1—0.4mg%)

  • Transaminases—SGOT/SGPT/LDH

    hepatocyte damage hypoxia/drugs/viruses

    Extrahepatic—heart/lungs/skeletal ms

    Marked (3x)-ac. Hep damage

  • Alkaline phoshphatase - bile duct cells

    slight obstruction (3x)

    bone –extrahep source

  • S. Albumin

  • 5- Nucleotidase

  • GGT

    Prehepatic / Hepatic / Posthepatic J ?

Obst. J



Spectrum of liver disease
SPECTRUM OF LIVER DISEASE

  • Parenchymal-Acute & Chronic Hepatitis

    -Hepatic Cirrhosis (+ portal

    hypertension)

  • Cholestatic -Intrahepatic – viral hepatitis

    – drug induced

    -Extrahepatic (Obstructive jaundice)

    – Calculi, stricture, growth.

    Parenchymal disease ultimately possesses an obstructive component & Obstructive disease produces cellular dysfunction.

    Clinical Hallmarks ?

Obst. J


Signs symptoms
Signs &Symptoms

  • Prog sev jaundice

  • Dark urine

  • Clay coloured stools

  • Pruritis

  • High fever+ chills

  • Biochemical hallmarks

Obst. J


Obstructive jaundice1
Obstructive Jaundice

  • Primary mechanism- Obst. of E.H. bile duct.

  • Bile duct pressure -

    Normal – 10-15 cm H2O

    > 15 cm → bile flow decreases

    > 30 cm → bile flow stops

Obst. J


Pathophysiological consequences
Pathophysiological consequences

Obst. J

Bile Acids are potent toxins


Endotoxemia in obstructive jaundice
Endotoxemia in obstructive jaundice

Bile salts are surfactants----disrupt endotoxins

Causes of endotoxemia

  • Absence of bile in intestine  intest.bact. Flora

  • Breakdown of GI mucos. barrier- bact. translocation

  • Hepatic RES function clearance of endotoxins

    Systemic Alterations – CVS ?

Obst. J


Systemic alterations
Systemic alterations

  • Circulatory homeostasis

    CHOLEMIA ●vasodepressor effect on BVs

    ● cardiodepressor  LVF

    ● PVR   BP  sympath + renal & cerebral vasoconstriction

    ●redistribution of TBV  trapping of blood in splanc. Circulation  effective BV

    ● NO - insensitive to vasoconstrictors

     Hypotension & circulatory collapse

Obst. J


Renal system
Renal system

  • Mild renal vasoconstriction

  • Renal hypoperfusion( hypovolemia)

  • Refractoriness of tubules to ADH

  • Endotoxemia

Obst. J


Renal system1
Renal System

  • Acute Renal Failure

  • Hepatorenal Syndrome

Obst. J


Renal system2
Renal system

Hepatorenal Syndrome

  • Oliguria

  • Inability to excrete Na in urine( 10mmol/l)

  • Functional change

  • Normal renal blood flow

  • Treatment : Prevention-identify high risk patients

Obst. J


Systemic alterations1
Systemic alterations

  • Coagulopathy(low grade DIC)

    Impaired platelet function

     FDP---inhibition of fibrinolysis

     Endotoxins

  • Hm gastritis & stress ulcers

  • Impaired wound healing

Obst. J



Problems
PROBLEMS

DUE TO DYSFUNCTION OF LIVER ITSELF :

- Low serum proteins

- Coagulopathy

- Drug metabolism and disposition

- Metabolic derangement - Hypoglycemia

- Electrolyte imbalance

- Haematological - Anaemia

– Thrombocytopenia

– Leucopenia

– DIC

- Deficiency of fat soluble vitamins (A, D, E, K)

- Increased serum cholesterol (atheromatous changes)

Obst. J


Problems1
PROBLEMS

DUE TO INVOLVEMENT OF OTHERSYSTEMS

  • CVS– TBV , PVR , Circulatory collapse

  • Renal - pre renal azotemia

    - Hepatorenal failure

  • GIT - Hm gastritis & stress ulcers

  • Resp.– Arterial Hypoxemia

    - vulnerability to pulmonary infection

  • CNS – Hepatic encephalopathy

    Problems related to surgery ?

Obst. J


Problems related to surgery
Problems related to surgery

  • Whipple’s procedure---Carc. Head of panc

  • Distal gastrectomy,PJ, HJ, GJ

  • Major surgery---long duration

  • Increased blood loss/fluid shifts

  • Wide incision---Roof top—warrants good postoperative analgesia

  • Extensive monitoring reqd for favourable outcome

Obst. J


Risk factors
Risk Factors

  • Age > 60yrs

  • Albumin < 30gm%

  • Preop. renal dysfunction

  • Long standing biliary obstruction  infection  sepsis

  • Weight loss

    Serum creatinine & Sepsis—prognostic factors

    Periop CVS collapse & renal failure

Obst. J


Preoperative assessment
Preoperative Assessment

OBJECTIVES

  • Assess the type and degree of liver dysfunction.

  • Assess effect on other system.

  • To ensure – post operative facilities (High risk patient).

Obst. J


Preoperative assessment1
Preoperative Assessment

  • History

  • Clinical examination

  • Investigations ???

    Unexplained jaundice of 4wks duration or longer

    will prove to be caused by obstruction in nearly

    75% patients

    Blumgart L

Obst. J


Preoperative investigations
Preoperative Investigations

To know the pattern of disease :

­ S. Bilirubin

­ SGOT, SGPT 90% predictive

­ alk. phosphatase

Obst. J


Preoperative investigations1
Preoperative Investigations

To judge the synthetic ability of liver

  • Serum albumin– < 2·5 gm% - severe damage

  • Albumin/globulin ratio – reversed.

  • Prothrombin time –> 1·5 sec. Over control

    – INR - > 1.3

    (D/D – Par entral Vit. K – Obst. Jaundice)

Obst. J


To assess general condition of patient

(i) Haematological · Hb

TLC, DLC

Platelet Count Clotting factors (PT, PTTK)

BT

(ii)Cardiorespiratory

Chest X-ray

ECG

Blood gases

(iii) Metabolic-

Serum proteins

Serum glucose

Electrolyte

Urea / Creatinine

Urinary-Urea/ Creatinine

-Electrolyte

(iv) Hepatic imaging

(v) Microbiological –

- Culture

-Hep. B marker

- Viral antibodies

To assess general condition of patient

Obst. J


Preoperative management
Preoperative management

  • Avoid prolonged hyperbilirubinemia

  • Treat infection –cholangitis

  • Use Aminoglycosides carefully

  • Avoid pre renal failure

  • Correct Anaemia/Coagulation/hypoalbuminemia

  • Avoid all NSAIDS

  • I/V saline & mannitol pre & postop

Obst. J


Preoperative management1
Preoperative management

No conclusive evidence for –

  • Preop percutaneous biliary drainage

  • Gut sterlization

  • Polymyxin B

  • Oral bile salts

    Pre medication ?

Obst. J


Premedication
Premedication

  • Anxiolytic – oral short acting BDZ

  • Oral H2 antagonist

  • Vit. K (Obst. J) – 10 mg B D X 3 day

  • If Bilirubin > 8 mg% –

    · I/V fluid – 1-2 ml/kg/hr.

    · Mannitol – 100 ml of 20% 2 hrs preop.

  • Order morning PT / S. Electrolyte

  • Preop urinary catheter & CVP

Obst. J


Anaesthetic management
Anaesthetic Management

General Considerations

Minimize physiological insult to liver & kidney

  • Maintain O2 supply – demand relationship in liver.

    →Adequate pulmonary ventilation and cardiovascular fn.

  • Maintain renal perfusion

    →Avoid Hypotension, hypoproteinemia & Hypoxia

    → meticulous fluid balance

    Choose appropriate anaesthetic agent

    Metabolism of drugs + Effect on HBF.

    Induction ?

Obst. J


Anesthetic technique
Anesthetic technique

  • General anesthesia

  • Preoxygenation

  • Induction - Thiopentone

    Propofol

  • Muscle relaxant –

    Suxamethonium

    Vecuronium 0.15mg/kg Rocuronium0.6mg/kg

    Atracurium(DOC)

  • Opioids ?

Obst. J


Anesthetic technique1
Anesthetic technique

  • Opioids – Well tolerated

    smaller doses

    Morphine—ph-II reac.

    fentanyl(DOC)

    spasm of sphincter of Oddi

Obst. J


Anesthetic technique2
Anesthetic technique

Spasm of sphincter of Oddi

  • Interpretation of operative cholangiography & biliary pressures

  • All patients do not show this response

  • Incidence of spasm is very low

  • Intraop manipulation of BD system  spasm

  • Treatment

Obst. J


Anesthetic technique3
Anesthetic technique

Volatile Anesthetics

  • Useful & well tolerated

  • Can be entirely eliminated

  • Disadv- CVS instability  vasodilation perf. Press.  blood velocity  oxygen extraction  HBF & oxygen supply

  • Isoflurane—best maint. of HBF & oxygen

    IPPV ?

Obst. J


Anesthetic technique4
Anesthetic technique

IPPV –

- Maintain eucapnia

- Liver low pr.tissue bed

- Avoid large VT & high airway pressures

Obst. J


Anesthetic technique5
Anesthetic technique

  • Maintenance of BV and Renal function

  • Mannitol

  • Frusemide

  • Dopamine

  • Adequate blood/component replacement

Obst. J


Monitoring
Monitoring

  • BP,HR,SpO2

  • EtCO2

  • CVP

  • Urine output

  • Core temp

  • NMJ monitoring

  • Blood loss

Biochemical

B.Sugar,ABG

S.Electrolytes

Hematological

Hb,PT,,PTTK,TEG

Obst. J


Postoperative management
Postoperative management

All well  Extubate

Unstable

- Continue IPPV in Post.op. period

- Fluid & Electrolyte imbalance

corrected

- CVS stability achieved.

- Hypothermia corrected.

- Urine Output 1 ml/kg/hr.

Adequate analgesia (Small doses)

Blood / blood product replaced.

Antibiotics + H2 receptor antagonist

Obst. J


Thank you
Thank You

[email protected]

Obst. J


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