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Anaesthetic management of obstructive jaundice. Dr. S. Parthasarathy MD., DA., DNB, MD ( Acu ), Dip. Diab.DCA, Dip. Software statistics PhD ( physio ) Mahatma Gandhi Medical college and research institute , puducherry - India. Anatomy . Functions of liver . The liver is vital for

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anaesthetic management of obstructive jaundice

Anaesthetic management of obstructive jaundice

Dr. S. Parthasarathy

MD., DA., DNB, MD (Acu),

Dip. Diab.DCA, Dip. Software statistics

PhD (physio)

Mahatma Gandhi Medical college and research institute ,puducherry- India

functions of liver
Functions of liver
  • The liver is vital for
  • protein synthesis
  • glucose homeostasis
  • bilirubin excretion
  • toxin removal
  • the liver has a substantial functional reserve because of its dual blood supply: portal-venous (75%) and hepatic-arterial (25%).
slide4

The liver conjugates bilirubin, produced from the degradation of the haemoglobin of red cells that are at the end of their normal life span.

  • This now water-soluble form of bilirubin is then excreted into the bile ducts and thence into the small intestine
physiology
Physiology
  • Bile acids are derivatives of cholesterol synthesized in the hepatocyte.
  • Cholesterol, ingested as part of the diet or derived from hepatic synthesis is converted into the bile, which are then conjugated to an amino acid (glycine or taurine) to yield the conjugated form that is actively secreted into cannaliculi.
pathophysiology of obstruction
Pathophysiology of obstruction
  • As conjugated bilirubin is water-soluble it will be excreted in the urine which becomes dark.
  • Stools are pale as a result of poor lipid absorption.
  • the absorption of vitamin K is dependent on the excretion of bile salts into the small intestine.
obstructive jaundice causes
Obstructive Jaundice – causes
  • extrahepaticcholestasis
  • choledocholithiasis,
  • tumors of the bile ducts and pancreas, postoperative strictures,
  • primary sclerosingcholangitis,
  • acute or chronic pancreatitis
obstructive jaundice causes1
Obstructive Jaundice – causes
  • intrahepaticcholestasis

carcinomas of the intrahepatic ducts,

primary sclerosing hepatitis

bacterial cholangitis,

  • hepatic metastases,
bile salts increase
Bile salts increase
  • so what ??
  • Bile salts cause prolong steroid NMB ARF by ATN

Cardiac arrhythmias

bilirubin increase
bilirubin increase
  • causes
      • ↓ SVR
      • Resistance to vasopressors
      • ↑ incidence of periop renal failure
what for it comes to us
What for - it comes to us ?
  • Surgery in these cases is to remove or bypass the obstruction or to drain infected obstructed bile.
  • i.e . CBD exploration
  • T tube insertion
  • Resection tumour
  • Choledochojejunostomy and bypass
surgery
Surgery??
  • CTP class C,
  • high MELD score,
  • ASA class V,
  • acute hepatitis,
  • severe coagulopathy,
  • severe extrahepatic manifestations of liver disease (eg, acute renal failure, hypoxia, cardiomyopathy).
bad cases
Bad cases
  • ERCP.
  • Percutaneous drainage
  • Come down on bilirubin, sepsis,
  • And try for major procedure
obs jaundice different
Obs. Jaundice different!!
  • Obstructive jaundice and hepatocellular disease may not go together
  • Only common thing
  • hyperbilirubinemia
preop assessment
Preop assessment
  • Routine assessment
  • Secretory function
  • Serum bilirubin1.25 mg = 20 µmol.
  • Jaundice can be prehepatic (haemolytic), hepatic (hepatocellular) or posthepatic (obstructive) in origin. Conj or unconj.
synthetic function
Synthetic function
  • Synthesis of many proteins takes place in the liver including most clotting factors and many carrier proteins, such as albumin, which to a varying degree bind drugs used during anaesthesia. How to assess??
  • Serum albumin
  • Prothrombin time and INR
metabolic function
Metabolic function
  • AlanineTransaminase (ALT) and AspartateTransaminase (AST)-raised menashepatocellular damage
  • Alkaline Phosphatase (ALP) GammaglutamylTransferaseSignifies obstruction
  • Abnormal liver enzyme results -- 4% of normal individuals and up to 36% of psychiatric patients
coagulation
coagulation
  • Prothrombin time and INR
  • Inj. Vit K as vit. K1 10-20 mg, 6-8hrly, 3 days
  • or FFP

Correct coagulopathy with vitamin K and FFP to achieve prothrombin time within 3 seconds of normal.

Sometimes DDAVP helpful

decreased synthetic function
Decreased synthetic function
  • evidence of decreased protein synthesis, with oedema and ascites,
  • signs of delayed clotting only partly reversed by vitamin K administration,
  • and even encephalopathy
  • Alkalosis, hepatic encephalopathy more concerned in liver diseases
child pugh score
Child-Pugh score
  • Measure 1 point 2 points 3 points
  • Total bilirubin,
  • (mg/dl) (<2) (2-3) (>3)
  • Serum alb >35 28-35 <28
  • INR <1.7 1.71-2.20 > 2.20
  • Ascites None Mild Severe
  • Hepatic encep.None Grade I-II Grade III-IV
slide21

Ascites ; paracentesis , diuretics

  • Minimize ascites why?
  • decrease risk of abdominal-wall herniation,
  • wound dehiscence, problems with ventilation.
  • Encephalopathy – lactulose,
  • Avoid – azotemia, GI bleed, constipation, alkalosis , sedatives
model for end stage liver disease
Model For End-Stage Liver Disease
  • MELD = 3.8[Ln serum bilirubin (mg/dL)] + 11.2[Ln INR] + 9.6[Ln serum creatinine (mg/dL)] + 6.4where Ln is the natural logarithm
  • MELD score > 14 – high risk
pre op investigations assessment
Pre op investigations & assessment
  • Hb%
  • Edema, ascites.
  • Nutrition
  • SPO2
  • Renal parameters.
  • Blood grouping typing
pre op
Pre op
  • Systolic and diastolic BP
  • Widened PP suggests CLD
  • The goal platelet count is >50-100 × 103/L
    • Correct preopHyponatremia

Hypokalemia

Hypomagnesemia

Hypoglycemia

More in liver disease

pre op asssesssment
Pre op asssesssment
  • CxR
  • ECG --CMP
  • USG, CT scan
  • Drug history
  • Alcoholism
  • HbsAg
infection more common
Infection more common
  • bacterial colonization of the biliary tree
  • impaired Kupffer cell function
  • defective neutrophil function
  • high rate of endotoxemia
  • Pre op antibiotics lactulose +
  • Rifaximin + broad spectrum antibiotics.
perioperative mortality ranged from 8 to 28 percent
Perioperative mortality ranged from 8 to 28 percent
  • An initial hematocrit value <30 percent
  • An initial serum bilirubin level >11 mg/dL (200 µmol/L)
  • A malignant cause of obstruction (eg, pancreatic carcinoma or cholangiocarcinoma)
respiratory system
Respiratory system
  • Hepatopulmonary syndrome

Pulmonary vascular dilatations, V A/Q mismatch

Reduced DLCO

  • Shift in oxyhemoglobin dissociation curve,
  • Portopulmonaryanastomoses
  • Pulmonary hypertension
respiratory system in obstruction alone
Respiratory system in obstruction alone ??
  • Restrictive lung pattern due to ascites
  • Expiratory airflow obstruction
  • Chest wall deformity,Pleural effusions
  • Panacinar emphysema
  • Pleuritis, Bronchitis / bronchiectasis
  • Hepatic hydrothorax
  • Impaired hypoxic vasoconstriction
  • Respiratory alkalosis
anaesthetics and liver disease
Anaesthetics and liver disease
  • Nitrous oxide (N2O) produces decrease in portal blood flow, and mild vasoconstriction of the hepatic arterial system
  • But safe in the absence of hypoxemia
  • N2O - safe
volatile anaesthetics
Volatile anaesthetics
  • All volatile anesthetics decrease hepatic blood flow
  • but desflurane and sevofluranehave the least significant effect on total hepatic blood flow and hepatic oxygen delivery,
  • halothane induces the most profound reductions in hepatic blood flow.
  • Isoflurane ideal – in coagulation problems
halothane
halothane
  • Do not use after prior history or family history of unexplained jaundice after halothane?
  • Do not use unless indicated?
halothane1
halothane

: "exercise care if obese, pre-existing liver disease, hypoxia likely“,

avoid if :

over 40 years old, long operation, biliary surgery, female patient, obese, allergic, sepsis, exposure less than 3 months previously

halothane and jaundice
Halothane and Jaundice
  • The incidence of this halothane hepatitis in adults is thought to be 1:7000-30,000 halothane anaesthetics.
  • rarer in paediatric patients and with the newer volatile agents.
  • The risk is higher in women, the middle aged and the obese.
iv drugs
IV drugs
  • propofol, etomidate, and midazolam,- safe
  • Benzodiazepines in low doses acceptable
  • Thio in high doses ??
  • Everything only in ??
relaxants
Relaxants
  • Atracurium safe
  • Steroidal NMB s ??
  • Suxa OK if renal parameters are normal
narcotics
Narcotics
  • All opioids increase tone of the common bile duct and the sphincter of Oddi
  • But make patients pain free.
  • Use remifentanyl
  • Can use butrum or nalbuphine if peropcholangiogram is planned
perop cholangiogram is planned
peropcholangiogram is planned
  • If narcotic induced spasm is problematic
  • Options are
  • Use NTG,
  • naloxone
  • Or Inj glucagon 2 mg IM
factors decrease liver blood flow
Factors decrease liver blood flow
  • IPPV + PEEP
  • Hypocapnia & hypoxia
  • Upright Posture, abd. surgery
  • Cirrhosis, Alfa stimulants
  • Ganglion Blockers,H2 blockers
  • Vasopressin
  • Anaesthetics – Volatile & intravenous
  • Important in liver diseases
monitoring
Monitoring
  • Simple chole or whipple s
  • If major ,
  • add
  • CVP, IBP, temperature,NMJ,urine,ecg
  • Hyperbilirubinemic Vent. Tachycardia
  • Difib. Available
renal protection
Renal protection
  • adequate hydration and a urine flow of at least 50ml/hr in the average adult patient.

If bilirubin 20 mg%

IV fluids 24 hours before surgery and for 36 hours, postop. IV mannitol 10% 0.5-1g/kg should be administered prior to surgery AND during surgery

  • Hydration and urine
renal protection1
Renal protection
  • Pre op albumin infusion decreased
  • Post op renal failure
epidural and ga
Epidural and GA
  • If Coagulation parameters are ok
  • Post op and intraop analgesia
  • Epidural narcotics
  • Avoid hypoxemia, ETCO2
  • Maintain hemodynamics, urine output
malignancy
malignancy
  • Surgery – palliative or radical
  • Splanchnic plexus block with alcohol
  • Possibility of thrombosis
post op
Post op
  • Pain
  • Hepatic flow , jaundice, encephalopathy
  • Renal protection
  • Oxygen and hemodynamics.
child reading abcd
Child reading ABCD
  • Child – child pugh criteria
  • A – antibiotics
  • B – blood, biliary spasm
  • C – coagulation
  • D – diuretics