Obs. J Obs. J Obstructive Jaundice – Whipple’s Obstructive Jaundice – Whipple’s Operation Operation Anesthetic Management Anesthetic Management Munisha Agarwal Munisha Agarwal Professor Professor Deptt. of Anaesthesiology Deptt. of Anaesthesiology & Intensive Care & Intensive Care L N Hospital & Maulana L N Hospital & Maulana Azad Medical College Delhi Azad Medical College Delhi
This document is posted to help you gain knowledge. Please leave a comment to let me know what you think about it! Share it to your friends and learn new things together.
Glycogen stores 75gm 24—48hrsGlycogen stores 75gm 24—48hrs Anesthesia – gluconeogenesisAnesthesia – gluconeogenesis Provide ext. source of glucoseProvide ext. source of glucose
Obst. JObst. J
Fat metabolismFat metabolism
Synthesis of lipo-proteins & Synthesis of lipo-proteins & cholesterolcholesterol
Oxidation of FA to ketone bodiesOxidation of FA to ketone bodies
Obst. JObst. J
Protein MetabolismProtein Metabolism
Deamination of AADeamination of AA Formation of ureaFormation of urea Plasma proteinsPlasma proteins
- - All except y globulin & factor VIIIAll except y globulin & factor VIII
- Albumin daily prod. 10—15g/d (3.5-- Albumin daily prod. 10—15g/d (3.5-5.5gm%)5.5gm%)
- liver disease - liver disease alb alb glob glob
Albumin ?Albumin ?
Obst. JObst. J
Protein synthesisProtein synthesis
Plasma O. P.Plasma O. P. Drug bindingDrug binding CoagulationCoagulation Hydrolysis Hydrolysis
Obst. JObst. J
Drug bindingDrug binding
Drugs reversibly combine with AlbuminDrugs reversibly combine with Albumin albumin albumin binding sites binding sites free drug free drug Albumin < 2.5gm%Albumin < 2.5gm% Acute Hepatic dysfunction ?Acute Hepatic dysfunction ?
Coagulation ?Coagulation ?
Obst. JObst. J
Drug bindingDrug binding
Acute hepatic dysfunction - drug Acute hepatic dysfunction - drug binding not affectedbinding not affected
T ½ AlbuminT ½ Albumin : 14 – 21 days : 14 – 21 days CoagulationCoagulation : affected (2—6hrs) : affected (2—6hrs)
Vitamin K dependent Coag. Factors?Vitamin K dependent Coag. Factors?
Obst. JObst. J
CoagulationCoagulation
Prothrombin, fibrinogenProthrombin, fibrinogen
Factor V, VII, IX, X ( except VIII)Factor V, VII, IX, X ( except VIII)
Deranged Coagulation ?Deranged Coagulation ?
Obst. JObst. J
CoagulationCoagulation
Deranged coagulationDeranged coagulation ed synthesis of Clotting factorsed synthesis of Clotting factors ed PT Vit. K deficiency d/t biliary ed PT Vit. K deficiency d/t biliary
obstruction obstruction absence of bile saltsabsence of bile salts ThrombocytopeniaThrombocytopenia ed Fibrinolysinsed Fibrinolysins
Obst. JObst. J
CoagulationCoagulation
Evaluate PT/ PTTK/ BTEvaluate PT/ PTTK/ BT LFT grossly deranged before LFT grossly deranged before
coagulation abnormalities appearcoagulation abnormalities appear 20%--30% activity required for normal 20%--30% activity required for normal
coagulationcoagulation TT1/2 of 1/2 of clotting factors produced in clotting factors produced in
liver is very short (in hrs)liver is very short (in hrs) Ac. Hep dysfunction Ac. Hep dysfunction Coag. Abn. Coag. Abn.
Obst. JObst. J
Drug metabolismDrug metabolism
- Lipophilic - Lipophilic →water soluble, less reactive→water soluble, less reactive
Enzymatic reactionEnzymatic reaction
phase I - oxidation (Cyt P - oxidation (Cyt P450450))
Serum bile acids—pruritusHypercholesterolemia-Ahteromas, Xanthomas
Systemic effect-CVS/renal/ GIT
Absence of bile in intestineMalabsorp steatorrhoea
Vitamin A,D, E, KEscape of endotoxins into
portal blood
Bile Acids are potent toxins
Obst. JObst. J
Endotoxemia in obstructive jaundiceEndotoxemia in obstructive jaundice
Bile salts are surfactants----disrupt endotoxins
Causes of endotoxemiaCauses of endotoxemia
Absence of bile in intestine Absence of bile in intestine intest.bact. Floraintest.bact. Flora Breakdown of GI mucos. barrier- Breakdown of GI mucos. barrier- bact. translocationbact. translocation Hepatic RES function Hepatic RES function clearance of endotoxinsclearance of endotoxins
CHOLEMIA CHOLEMIA ●● vasodepressor effect on BVsvasodepressor effect on BVs
● ● cardiodepressor cardiodepressor LVF LVF
●● PVR PVR BP BP sympath sympath + + renal & cerebral renal & cerebral
vasoconstrictionvasoconstriction
●● redistribution of TBV redistribution of TBV trapping trapping of blood in splanc. Circulation of blood in splanc. Circulation effective BV effective BV
● ● NO - insensitive to NO - insensitive to vasoconstrictorsvasoconstrictors
Mild renal vasoconstrictionMild renal vasoconstriction Renal hypoperfusion( hypovolemia)Renal hypoperfusion( hypovolemia) Refractoriness of tubules to ADHRefractoriness of tubules to ADH EndotoxemiaEndotoxemia
Obst. JObst. J
Renal SystemRenal System
Renal vasoconstriction
Arterial hypotensionNephrotoxic bile salt
& pigmentsEndotoxins &
Inflammatory mediators
• Acute Renal FailureAcute Renal Failure
• Hepatorenal SyndromeHepatorenal Syndrome
Obst. JObst. J
Renal systemRenal system
OliguriaOliguria Inability to excrete Na in Inability to excrete Na in
-- Hep. B markerHep. B marker-- Viral Viral antibodiesantibodies
Obst. JObst. J
Preoperative managementPreoperative management
Avoid prolonged hyperbilirubinemiaAvoid prolonged hyperbilirubinemia Treat infection –cholangitisTreat infection –cholangitis Use Aminoglycosides carefullyUse Aminoglycosides carefully Avoid pre renal failureAvoid pre renal failure Correct Correct
Anaemia/Coagulation/hypoalbuminemiaAnaemia/Coagulation/hypoalbuminemia Avoid all NSAIDSAvoid all NSAIDS I/V saline & mannitol pre & postopI/V saline & mannitol pre & postop
Obst. JObst. J
Preoperative managementPreoperative management
No conclusive evidence for –No conclusive evidence for –
Preop percutaneous biliary drainagePreop percutaneous biliary drainage Gut sterlizationGut sterlization Polymyxin BPolymyxin B Oral bile saltsOral bile salts
Pre medication ?Pre medication ?
Obst. JObst. J
PremedicationPremedication
Anxiolytic – oral short acting BDZAnxiolytic – oral short acting BDZ Oral H2 antagonistOral H2 antagonist Vit. K (Obst. J) – 10 mg B D X 3 dayVit. K (Obst. J) – 10 mg B D X 3 day If Bilirubin > 8 mg% –If Bilirubin > 8 mg% –
spasm of sphincter of Oddispasm of sphincter of Oddi
Obst. JObst. J
Anesthetic techniqueAnesthetic technique
Spasm of sphincter of OddiSpasm of sphincter of Oddi Interpretation of operative Interpretation of operative
cholangiography & biliary pressurescholangiography & biliary pressures All patients do not show this responseAll patients do not show this response Incidence of spasm is very lowIncidence of spasm is very low Intraop manipulation of BD system Intraop manipulation of BD system
spasmspasm Treatment Treatment
Obst. JObst. J
Anesthetic techniqueAnesthetic technique
Volatile AnestheticsVolatile Anesthetics Useful & well toleratedUseful & well tolerated Can be entirely eliminatedCan be entirely eliminated Disadv- CVS instability Disadv- CVS instability vasodilation vasodilation