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Obstructive Jaundice Case Discussion Speaker: Dr S.N.Bhagirath Panelists: Dr Hemalatha.S Dr Manjula.B.P. Dr Krithika Devi

Obstructive Jaundice and Anesthesia

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A Case of Obstructive Jaundice and administration of Anesthesia in such a case

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Page 1: Obstructive Jaundice and Anesthesia

Obstructive JaundiceCase Discussion

Speaker: Dr S.N.Bhagirath

Panelists: Dr Hemalatha.S Dr Manjula.B.P. Dr Krithika Devi

Page 2: Obstructive Jaundice and Anesthesia

Case Presentation

Patient details Name: Puttasomachari Age: 68 years Sex: male I.P.No.: 216363

Chief Complaints Pain abdomen – 20 days Generalised Itching – 20 days Fever – 3 days

Page 3: Obstructive Jaundice and Anesthesia

Case Presentation……..contdHistory of presenting illness

Pain abdomen Itching Fever

Colicky type

Gradual in onset

Intermittent in nature

Over right upper part of abdomen

Non radiating

No aggravating/relieving factors

20 days duration

Gradual in onset

Progressive in nature

Generalised in extent

Relieved on medication

20 days duration

Low grade

Intermittent in nature

Not associated with chills and rigors

No diurnal variation

Relieved on medication

3 days durationHistory of yellowish discolouration of eyes and urine since 15 days

No history of Diabetes Mellitus, Hypertension, Bronchial asthma or Epilepsy

Page 4: Obstructive Jaundice and Anesthesia

Case Presentation……..contd

Past history

No history of similar complaints in the past.

History of weight loss present since last three months (has lost about 6 kgs).

No history of previous surgery, Jaundice or contact with

jaundiced patient.

No history of drug intake except for consumption of Tab. Atarax (hydroxyzine – 25 mg) for itching and Tab. Crocin (Paracetamol – 500 mg) for fever.

No history of blood transfusions.

Page 5: Obstructive Jaundice and Anesthesia

Case Presentation……..contd

Family history

No history of similar complaints in the family was noted. Personal history

Diet: Vegetarian

Appetite: reduced

Bowel & bladder habits: Normal. (pale stools)

Sleep: disturbed (due to itching)

Habits: Smoker since 20 years ( 8 beedis/day). Not an

alcoholic.

Page 6: Obstructive Jaundice and Anesthesia

Case Presentation……..contd

General Physical Examination

An elderly male patient moderately built and nourished. Conscious and

oriented.

Pallor - +, Icterus - +, No cyanosis, oedema, clubbing

Scratch marks - ++ over the abdomen and peripheries.

Pulse rate – 62/min;

Blood pressure – 130/80 mm of hg;

Respiratory rate – 16/min;

Page 7: Obstructive Jaundice and Anesthesia

Case Presentation……..contd

General Physical Examination

.

Per abdominal examination: Inspection: Normal in size and shape.No dilated veins, scars and sinuses.All quadrants move correspondingly with respiration. Palpation: Soft. Tenderness in right hypochondrium and epigastrium. Palpable hard mass of about 5 x 3 cms felt in the epigastrium with an irregular border. Hepatomegaly +, 3 cms below the costal marginNo SplenomegalyNo free fluid

Page 8: Obstructive Jaundice and Anesthesia

Case Presentation……..contd

General Physical Examination

Cardiovascular system: S1 S2 heard, No murmurs heard.

Respiratory System: Normal Vesicular Breath Sounds heard, No added

sounds.

Central Nervous System: Normal. No neurological deficits

Impression: Obstructive Jaundice with probable carcinoma of head of pancreas

Page 9: Obstructive Jaundice and Anesthesia

Case Presentation……..contdInvestigations

Hb: 10.4 gm%Differential count: Neutrophils – 71 Lymphocytes – 24 Monocytes – 02 Eosinophils – 03 Total count – 9, 800Platelets: 2.73 lakhs/mm3

PT INR: 1.0BT: 3’ 00”

CT: 4’ 00”

RBS: 99 mg/dlUrea: 30 mg/dl Creatinine: 1.1 mg/dlNa+: 135 mEq/l, K+: 3.9 mEq/l, Cl-: 104 mEq/l

Page 10: Obstructive Jaundice and Anesthesia

Case Presentation……..contdInvestigations……ccontd

LFT: Total Bilirubin: 9.0 (0.1 – 1.0)

Direct Bilirubin: 5.3 (0.0 – 0.2)

Indirect Bilirubin: 3.7

Albumin: 2.8 (3.4 – 5.0)

A/G Ratio: 0.9 (1.2 – 2.5)

AST: 39 (0 – 40)

ALT: 32 (0 – 40)

Alkaline Phosphatase: 570 (37 – 147)

HIV 1 & 2: Not detected, HBsAg: Not detected

USG: Intra Hepatic Biliary radical dilatation in its entire length probably

due to stricture.

Page 11: Obstructive Jaundice and Anesthesia

Case Presentation……..contdInvestigations……ccontd

ECG: Sinus rhythm. Within normal limits. Heart rate: 60/min.

2D ECHOCARDIOGRAPHY: Normal Left Ventricular systolic function

No Regional Wall Motion abnormalities

Ejection fraction: 59 %

Upper G.I. Endoscopy: bulging growth in Periampullary region.

C.T. Scan: Moderated dilatation of intrahepatic and common bile ducts.

Chest X – Ray: Hyperinflated lung fields (COPD changes)

Arterial Blood Gas Analysis: Mild hypoxia.

Page 12: Obstructive Jaundice and Anesthesia

Case Presentation……..contd

Management Plan

Kausch – Whipple’s Procedure

Page 13: Obstructive Jaundice and Anesthesia

Discussion with elaborationsHistory of presenting illness

Pain abdomen

Colicky type

Gradual in onset

Intermittent in nature

Over right upper part of abdomen

Non radiating

No aggravating/relieving factors

20 days duration

Biliary colic•Severe• intermittent•Colicky painPancreatic Pain•Dull, continous pain radiating to back• aggravated by food• relieved by sitting up or leaning forward

Hepatomegaly•Dull, continous dragging type of pain in right hypochondrium – stretching of Glisson’s capsule

Page 14: Obstructive Jaundice and Anesthesia

Discussion with elaborationHistory of presenting illness

Fever

Low grade

Intermittent in nature

Not associated with chills and rigors

No diurnal variation

Relieved on medication

3 days duration

Viral hepatitis

• Fever at onset witharthralgias

Cholangitis

• Fever with rigors

Neoplasm

• low grade fever

Page 15: Obstructive Jaundice and Anesthesia

Discussion with elaborationHistory of presenting illness

History of yellowish discolouration of eyes and urine since 15 days

Normal range of plasma bilirubin•Total - 0.3 – 1.0 mg/dl• Indirect – 0.2 – 0.7 mg/dl• Direct – 0.1 – 0.4 mg/dl

Clinically obvious2 – 2.5 mg/dl

•Sclera•Under surface of tongue•Palms•Nails•Skin

Bilirubin has affinity to elastin (collagenous tissue) – scleral icterus is more sensitive.

Differential diagnosis of icterus

-Carotemia(scleral icterus is absent)

Page 16: Obstructive Jaundice and Anesthesia

Discussion with elaborationPast history

No history of similar complaints in the past. History of weight loss present since last three months (has lost about 6 kgs). -suggestive of malignancy

No history of previous surgery -retained or recurrent stone, biliary structure, recurrent obstruction from enlarging tumor

-anaesthesia exposure (post operative hepatic dysfunction, halothane hepatitis)

Jaundice-relapsing hepatitis, choledocholithiasis

Page 17: Obstructive Jaundice and Anesthesia

Discussion with elaborationFamily and personal history

Family history of CholestasisProgressive Familial Intrahepatic Cholestasis syndrome (Dubin Johnson & Rotor syndrome)α1 antitrypsin deficiency Family history of jaundiceWilson’s diseaseProgressive Familial Intrahepatic Cholestasis syndrome (Dubin Johnson & Rotor syndrome)α1 antitrypsin deficiency

Alcohol – Alcoholic hepatitis can lead to cholestasis

Page 18: Obstructive Jaundice and Anesthesia

Discussion with elaboration

General Physical

examination

BMI

Vital signs

Pallor: Gastrointestinal bleeding

IcterusLemon yellow – HemolyticGreenish yellow – ObstructiveOrange yellow - Hepatocellular

Pedal edema - hypoproteinemiaScratch marks - pruritis

Xanthoma - hypercholesterolemia

Bruises - Coagulopathy

Fat Soluble vitamin deficiency• Vitamin A deficiency – Bitot’s spot, hyperpigmentation• Vitamin K deficiency - Ecchymoses

Page 19: Obstructive Jaundice and Anesthesia

Discussion with elaborationAbdominal Examination

Inspection: Abdominal distension -ascitesDilated abdominal vessels- cirrhosisOperative scar-previous surgery

PalpationRight upper quadrant tenderness (Murphy’s sign)-cholecystitis, cholangitisHepatomegaly: tender-Right heart failure, acute hepatitis, obstruction in biliary tract; Non-tender nodular–malignancy or infiltrative process e.g. amyloidosisSplenomegaly-infective hepatitis, portal HT due to cirrhosis, Right heart failure, haemolytic anaemiaDistended palpable GB (Courvoisier’s law) - in malignant obstruction of distal common bile ductFree fluid: Malignant ascites or non malignant ascites

Page 20: Obstructive Jaundice and Anesthesia

Discussion with elaborationDifférences between extrahepatic/ intrahepatic Cholestasis

Extrahepatic IntrahepaticAbdominal Pain Present Absent

Fever Present Absent

Prodrome Absent Present

Drugs Absent Present

History of surgery Present Absent

Risk factors like transfusion Absent Present

Family History Absent Present

Stigma of cirrhosis Absent Present

Encephalopathy Absent Present

PT Normalizing with Vitamin K Present Absent

Page 21: Obstructive Jaundice and Anesthesia

Clinical pointersNature of Jaundice

Progressively worsening jaundice -  Malignant  obstruction,  primary  biliary cirrhosis,  familial cholestasis, primary sclerosing cholangitis, advanced end stage liver disease

Intermittent jaundice -  choledocholithiasis,  ampullary  carcinoma,  biliary ascariasis, relapsing viral hepatitis

Association with drug intake

Cholestatic – oral contraceptives, anabolic steroid, chlorpromazine, carbamazepine, antibiotics- erythromycin, rifampicinHepatitis- INH, halothane, phenytoin, methyldopa,

acetaminophen

Fatty liver- tetracycline, valproateToxic necrosis- acetaminophen, CCl4

Page 22: Obstructive Jaundice and Anesthesia

Clinical pointersWhy pruritis..?

Central mechanism: ↑central opioidoergic tone in patients with cholestasis

Peripheral Mechanism: accumulation of numerous substances e.g. bile acids, histamine, serotonin & endogenous opoids in the systemic circulation subsequent to failure of elimination

Treatment:

Opioid antagonists, Cholestyramine, Rifampicin (Induce CP450 which inactivates pruritogen), Phenobarbitone, Oral guar gum, 5-HT antagonist, UDCA (Urso deoxy cholic acid), Propofol, Lidocaine, Charcoal hemofiltration, Plasmapheresis, Ileal diversion, Liver transplantation.

Page 23: Obstructive Jaundice and Anesthesia

Bilirubin MetabolismReticuloendoth

elial system

Unconjugated bilirubin + Albumin

Bilirubin + glucuronic acid bilirubin di/ mono glucuronide

Conjugated bilirubin is hydrolyzed and converted to urobilinogen by intestinal pathogens

Stercobilin

Faeces

90% urobilinogen back to liver

10% urobilinogen

into systemic circulation Urobili

n

Page 24: Obstructive Jaundice and Anesthesia

Clinical pointersObstructive Jaundice

Intrahepatic causes

Familial/ hereditary disorders – • Dublin Johnson syndrome, • Rotor syndrome, • Cholestatic jaundice of pregnancy, • Recurrent intrahepatic cholestasis

Acquired–•Cholestatic  drugs , •viral and alcoholic hepatitis, •TPN induced, •Biliary Cirrhosis, •sclerosing cholangitis

Page 25: Obstructive Jaundice and Anesthesia

Clinical pointersObstructive Jaundice

Extrahepatic causesBenignGallstone/ Choledocholithiasis - most common causeClinical features - Previous history of dyspepsia, Intermittent Pyrexia/ Rigors, Pain, jaundice (Charcot’s triad), O/e – positive Murphy’s sign                                Chronic pancreatitis, Strictures – iatrogenic, traumaParasitic infections – ascariasis, clonorchiasis, Biliary atresia , Choledochal cysts

MalignantCarcinoma of pancreas/ampulla/bile duct/gall bladderClinical features – Painless, progressive deep Jaundice, Weight loss, Courvoisier’s sign - Palpable Gallbladder (exception ampullary Ca- intermittent jaundice d/t sloughing of tumour cells) 

Page 26: Obstructive Jaundice and Anesthesia

Clinical pointersObstructive Jaundice

Lab investigations – • ↑ conj. plasma bilirubin, •bilirubinuria, •absent urobilinogen in urine, •clay coloured stools, •↑ - ALP•5-NT

Page 27: Obstructive Jaundice and Anesthesia

Biochemical differentiators

Prehepatic Jaundice Hepatic Jaundice Post hepatic JaundiceSerum bilirubin          ↑ (mostly unconjugated)    ↑ (conj. & unconj.)        ↑ (conjugated.) Urine Urobilinogen            ++                             +                           - Urine Bile Salts                 absent                       + /                     + Urine Bilirubin                   --                             + / -                      ++ ↑↑ (high coloured)  Fecal stercobilinogen           ↑↑                         N or ↓                        absent (clay colour) Faecal fat                        N                         N or ↑                          ↑↑Enzymes SGOT / PT         N                            ↑↑                            N or ↑(AST / ALT)                  (> 800 IU/L)            50-100 IU/L Alkaline PO4                        N                       N or ↑ (x 1-2)              ↑↑ (x 3-10) Plasma albumin                  N                             ↓                           N or ↓

Prothrombin Time                N                            ↑↑                            ↑↑

Page 28: Obstructive Jaundice and Anesthesia

Clinical pointersConsequences of Obstructive Jaundice

• Decreased hepatocyte function• metabolic dysfunction of cyt450• decreased synthesis of albumin and clotting factors• decreased Kupffer cell activity• bilirubinemia, pruritis, CVS depression, nephrotoxicity, hypercholesterolemia, atheromas and xanthoma. • With absence of bile, endotoxins escape into portal blood• Malabsorption of fats and vitamin A, D, E and K• Acholic stools.

Page 29: Obstructive Jaundice and Anesthesia

Clinical pointers Investigative aids

Ultrasound - determines level & presence of intra and extrahepatic biliary dilatation - More sensitive than CT in detecting gall stone

CT - useful in obese and excessive bowel gas - stages and assesses operability of tumor

ERCP - allows biopsy, brush cytology - therapeutic – Sphincterotomy, stone removal, stricture dilatation.

PTC - 22G chiba needle, - allows biliary drainage and stenting

Page 30: Obstructive Jaundice and Anesthesia

Clinical pointers

Surgical procedures

•Ca Gall Bladder: Radical Cholecystectomy with wedge resection

and CBD excision

•Choledocholithiasis: ERCP removal or CBD exploration/ bilio-

enteric anastamoses

•Cholangio Ca: Liver resection and or local excision of the lesion

or Whipple

•Biliary Stricture: Hepatico-jejunostomy/ liver resection

•Periampullary Ca: Whipple’s Procedure

•Chronic Pancreatitis with head Mass: Whipple/ bilio-enteric

anastamoses

Page 31: Obstructive Jaundice and Anesthesia

Anaesthetic Perspectives

Cardiovascular system

circulating bile salts (cholemia) leads to

•Impaired myocardial contractility•Bradycardia•Vasodilatation ↓ ability to mobilise blood from splanchnic vasculature during Hemmorhage•↓ sensitivity to vasopressors•Hypotension & circulatory collapse• Small blood losses are poorly tolerated; therefore replace volume losses immediately in peri-operative period.

Page 32: Obstructive Jaundice and Anesthesia

Anaesthetic Perspectives

Renal System

Acute renal failure

•Etiology multifactorial                                             

•Arterial hypotension-myocardial depression

•Reduction in intravascular volume

•Nephrotoxicity - bile salt, endotoxins & inflammatory

mediators

•Incidence 5 -10%, mortality high 32 – 100%

•Level of hyperbilirubinemia correlates with postoperative

decrease in Creatinine clearance

Page 33: Obstructive Jaundice and Anesthesia

Anaesthetic Perspectives

Sepsis

can be due to

•Associated cholangitis and bactibilia•Absence of bile salts in intestine Escape of endotoxins from intestine into portal  

•blood

•Retention of bile solutes in liver ↓ Kupffer cell activity

•Prevention - Perioperative antibiotics and oral bile salts

Page 34: Obstructive Jaundice and Anesthesia

Anaesthetic Perspectives

Coagulopathy

1.Absence of bile salts in intestine Vitamin. K malabsorption (required for gamma carboxylation of glutamyl residues of factors II, VII, IX, X) ↑ PTCorrection - pre-op. Vitamin. K 10 mg OD × 3 days 2.  Long lasting biliary obstruction Sec. biliary cirrhosis ↓ syn. of coagulation factors (poor prognosis) Correction - transfusion of FFP

Page 35: Obstructive Jaundice and Anesthesia

Anaesthetic Perspectives

Multiple Vitamin Deficiency - A, D, E, K due to absence of bile salts in intestine(A- night blindness, D – osteoporosis and muscle weakness, E- leg cramps, K-easy bruising) Haemorrhagic gastritis and stress ulcer Impaired wound healing Altered drug handling due to cholestasis Long standing extrahepatic biliary obstruction > 1yr → biliary cirrhosis →      problems of liver dysfunction

Page 36: Obstructive Jaundice and Anesthesia

Anaesthetic Perspectives

LIVER FUNCTION TESTS  A.   Indices of hepatocellular damage 1. Transaminases      SGOT/SGPT   - 0 – 35 IU/L• SGOT (AST) - extrahepatic sources- heart /skeletal muscle/ kidney/ brain, less specific• SGPT (ALP) - primarily found in liver, more specific Viral hepatitis - SGOT/SGPTAlcoholic hepatitis - SGOT/SGPT > 2 (deficiency of pyridoxine-5-PO4)In advanced liver cell injury Transaminases level may actually be normal or low due to massive loss of parenchymal tissue

How does one assess liver functions..?

Page 37: Obstructive Jaundice and Anesthesia

Anaesthetic Perspectives

LDH – poor specificity3. Glutathione- S – transferase (GST) isoenzyme B – sensitive indicator of liver damageB.  Indices of Obstructed Bile Flow 1). Alkaline Phosphatase – 35 – 100 IU/LDerived from plasma membrane of bile duct cellsExtrahepatic sources- bone, intestine, liver, placenta2.) 5- Nucleotidase - confirms hepatic origin of ALP, specific for liver disease3). Gamma glutamyl transferase (GGT) – most sensitive indicator of biliary tract disease, but limited usefulness due to poor specificity

How does one assess liver functions..? …..contd

Page 38: Obstructive Jaundice and Anesthesia

Anaesthetic Perspectives

How does one assess liver functions..? …..contd

Aminotransferases             Alkaline PO4                    Diagnostic Likelihood                                                 Viral hepatitis                  Obstructive Jaundice > X 6                        < X 2.5            90%                                   10%< X 6                                   > X 2.5      10%                                     80% C.   Indices of hepatic synthetic function

1. Prothrombin time – factors II, V, VII & X

Coagulation. Factors have a short t ½; therefore PT is good indicator of liver function in both Acute & Chronic liver disease, good prognostic indicator of outcome of surgery in patients with liver disease Causes for prolonged PT independently of liver disease - Vit. K deficiency, Antibiotic therapy, DIC, Fibrinolysis, Coumarin administration

Page 39: Obstructive Jaundice and Anesthesia

Anaesthetic Perspectives

How does one assess liver functions..? …..contd

Serum albuminLong t ½ - 14-20days,Liver – substantial reserve for alb. syn., daily production 10—15g/d (3.5-5.5gm %)Functions - Plasma oncotic pressure, Transport vehicle, Drug bindingNot a good indicator for acute or mild liver damage

Indicator of severity of chronic. Liver disease (< 2·5 gm% - severe damage) D.   Indices of hepatic blood flow and metabolic capacity1. Indocyanine green (ICG) elimination test – for liver perfusion & function    ICG has high extraction ratio2. MERG (monoethylglycinexylidide) test – for liver function.    lidocaine is metabolised to MERG in liver

Page 40: Obstructive Jaundice and Anesthesia

Anaesthetic Perspectives

How does one assess liver functions..? …..contd

OTHER PREOPERATIVE INVESTIGATIONS1. Haematological inv - Hb – decreased in concealed blood Loss, haemolysis,                                        TLC, DLC - increased infection                                        Platelet Count, clotting studies   - BT, PT                                                              2. Urine analysis - Urobilinogen absent, Bilirubin & Bile Salts present 3. Metabolic - Serum   proteins, glucose, Urea - ↓ syn. in liver disease, Electrolyte 4. KFT – Urea, S. Creatinine, 5 Viral markers – HBV, HCV 6. Cardiorespiratory - Chest X-ray, ECG, blood gases

Page 41: Obstructive Jaundice and Anesthesia

Anaesthetic Perspectives

RISK FACTORS for operative mortality in obstructive

jaundice patients

•Hematocrit < 30 %

•S. bilirubin  > 11mg%

•Malignant cause of biliary obstruction

•Azotemia

•Hypoalbuminemia

•Cholangitis

Page 42: Obstructive Jaundice and Anesthesia

Anaesthetic Perspectives

Maintain hepatic blood flow and oxygenation AVOID:1. Sympathetic stimulation2. Hypotension (decreased venous return / cardiac output) caused by * Haemorrhage * Cardiac depressant drugs * Regional anaesthesia e.g.; thoracic epidural analgesia3. Hypocapnia & Hypoxemia4. Pressure effects caused by * Surgical retraction * Tumors * Ascites / Laparoscopy5. Hepatic venous congestion caused by * Head down position * IPPV with PEEP, Rt. side heart failure6. Hepatotoxic drugs  e.g. halothane or acetaminophen

ANAESTHETIC GOALS in Obstructive Jaundice patient

Page 43: Obstructive Jaundice and Anesthesia

Anaesthetic Perspectives

2. Maintain Renal functionsPreoperatively• Avoid NSAIDs and  nephrotoxic antibiotics e.g.; (aminoglycosides)•Oral bile salts to normalize gut flora•Prophylactic antibiotics to prevent sepsis•Drainage stent -↓ Hyperbilirubinemia•PTC, ERCP or papillotomyIntraoperatively•avoid hypotension & hypoxemia•avoid dehydration•Renal does dopamine /Mannitol / furosemide.

ANAESTHETIC GOALS in Obstructive Jaundice patient

Page 44: Obstructive Jaundice and Anesthesia

Anaesthetic Perspectives

Choosing appropriate anaesthetic agentNo drug is contraindicated in Cholestatic liver disease. per se. Other considerations  Coexisting hepatocellular disorderRenal dysfunctionHepatotoxic and Cholestatic drugs  Anaesthetic agent of choiceNot dependent on hepatic metabolismMaintains hepatic O2 supply – demand relationship

PREOPERATIVE PREPARATION for Anaesthesia

Page 45: Obstructive Jaundice and Anesthesia

Anaesthetic Perspectives

General anesthesia

Induction agent - Thiopentone/Propofol

slow titrated dose → avoid hypotension

gentle intubation → avoid sympathetic stimulation

Muscle relaxant

Suxamethonium – Rapid sequence Induction

Atracurium (drug of choice) - Hoffman’s elimination     

Vecuronium 0.15mg/ kg body weight 

PREOPERATIVE PREPARATION for Anaesthesia

Page 46: Obstructive Jaundice and Anesthesia

Anaesthetic Perspectives

Opioids  

•Fentanyl (DOC)- maintains hepatic oxygen supply – demand

•opioids can cause spasm of sphincter of Oddi (incidence < 3%)

leading to biliary colic , false + cholangiogram

•fentanyl> morphine> meperidine> butorphenol

•T/T naloxone, glucagon, atropine, nitroglycerine

Volatile Anesthetics

•Isoflurane - maintains hepatic blood flow & oxygen supply

•IPPV –- Maintain eucapnia, Avoid high airway pressures

Page 47: Obstructive Jaundice and Anesthesia

Anaesthetic Perspectives

Regional anaesthesia (Epidural anaesthesia) as supplement to G.A.Supplemental for intraoperative analgesia and for postoperative analgesiaConcerns –  coagulopathy & hypotension Intra Operative Monitoring RoutinePulse oximetry, ECG, NIBPEtCO2Urine outputCore temperatureNMJ monitoring Longer & extensive surgeriesIntra arterial and CVP monitoring. Biochemical – Blood Sugar, ABGs. Electrolytes.Haematology -Hb, PT

Page 48: Obstructive Jaundice and Anesthesia

Anaesthetic Perspectives

• Conscious, adequate neuromuscular recovery, vitals stable extubate oxygen enriched air•Else   - Continue IPPV• Correct Fluid & Electrolyte imbalance• Correct hypothermia• Achieve CVS stability•Adequate analgesia & chest physiotherapy•Antibiotics and  H2 receptor antagonist•Maintain urine output•Replace blood and blood products

Post operative Management

Page 49: Obstructive Jaundice and Anesthesia

References

Harrison’s Internal Medicine 16th Edition, p1888 –p1889

Clinical Anesthesia by Paul.G.Barash, 6th Edition, p1253

Page 50: Obstructive Jaundice and Anesthesia

References

Miller’s Anaesthesia, 7th Edition, p411, p1071

A Practice of anaesthesia, seventh Edition, Wylie and Churchill

Davidson, p1253

Page 51: Obstructive Jaundice and Anesthesia

References

Stoelting’s Anesthesia and co-existing Disease

Clinical Anesthesiology, Edward.G.Morgan, 4th Edition.