jaundice anaesthesia

1. OBSTRUCTIVE JAUNDICE
FOR WHIPPLE’S SURGERY
Case Presentation
MODERATORS : DR. MUNISHA AGARWAL, DR.
NISHKARSH GUPTA
PRESENTERS : DR. RAVI, DR. TANZIN

2. History
 Patient Ramesh , 52yrs old gentleman
 Resident of Paharganj, Delhi.
 Shopkeeper by occupation
 Hindu by religion

3.  Presented with chief complaint of:
Yellow discoloration of eyes since 4 months
Yellow discoloration of urine since 4 months
Chief Complaints

4. History of presenting illness
 Patient was apparently well 4 months back when he noticed yellowish
discoloration of eyes and urine, which was insidious in onset and was
gradually progressive; with accompanying passage of clay colored
bulky stools for same duration.
 Patient also complains of itching all over the body(developed after
the yellowish discoloration).
 There is associated anorexia and weight loss (approx. 4-5kg) in the
last 4 months.
 There was no history of pain abdomen preceding the onset of
jaundice or along with it.

5.  The patient had no h/o high grade fever with chills or rigor or
fluctuation of the jaundice
 There were no prodromal symptoms like fever, bodyache or
arthralgia preceding the onset of jaundice.
 The patient is not a known IV drug user/ prone to
tattooing/promiscuous behaviour.
 There is no h/o multiple blood transfusions, hematoma
formation,trauma.

6.  There is no history of Nausea, vomiting, melena, sensation of
fullness following meals.
 There is h/o breathlessness on exertion and easy fatiguability. There
is no h/o chest pain, cough, hemoptysis.
 No h/o headache, sleep disturbances, convulsions

7. Past history
 No history of any other comorbidities.
 No history of any jaundice in the past.
 No history of any surgery or hepato-biliary intervention in past.

8. Personal history
 Married, has a son, all in good health.
 His wife is a home maker and is in good health.
 He smokes an average of 6 cigarettes/ day, for the last 20 years.
 Sleep – normal
 No history of any alcohol addiction.

9. Family history
 Parents died due to old age.
 He has 2 brothers and 2 sisters, all healthy and alive.
 No history of jaundice, no h/o hemolytic anemia in family.

10. Treatment history
 No significant treatment history.
 No h/o steroid intake, herbal supplements.
 No h/o known drug allergy.

11. General Physical Examination
 Patient is alert , conscious, cooperative. Oriented to time place and
person
 Weight : 49kg, height : 160cm BMI : 19.14kg/m2
 Built – average
 Gait- normal
 Pallor – present
 Icterus – present
 Cyanosis, clubbing, lymphadenopathy, edema – absent
 No stigmata of liver failure – spider naevi, palmar erythema

12.  Neck veins – not engorged
 Neck LN – not palpable
 Skin-scratch mark present
no ulcers, petechiae present
 Spine – normal
no kyphoscoliosis

13.  Pulse 64/min, regular, normal volume and character
 Blood pressure- 110/80mm Hg, right arm, supine
 Respiration – 16/min regular
 Temperature – 98.4°F

14. Airway Examination
 Facies – Normal
 Dentition – normal, no loose or broken teeth/ artificial dentures
 Inter-incisor distance- 5 cm
 Modified Mallampati class- II
 Neck range of movement- Full, unrestricted
 Upper lip bite test – I
 Thyromental distance- 7 cm

15. Systemic examination- Abdomen
 Inspection
• Contour of abdomen – scaphoid, umbilicus – central, inverted
• Skin over abdomen – no visible swelling, scars, sinuses, venous
engorgement.
• No pulsations or visible peristaltic waves visible.
• External genitalia is normal, Hernial sites normal

16.  Palpation
On superficial palpation:
• Soft with no local rise in temperature
• No tenderness
On deep palpation:
• Liver is palpable 2 finger breadth below right costal margin, soft, non-
tender with smooth surface and sharp margin.
• A 7*4 cm firm non tender, globular, smooth surfaced lump in the right
upper abdomen moving with respiration and side to side. Its lateral,
medial and anterior margins are well defined with upper margin
continuous with the right costal margin
• Spleen is not palpable
• Hernial sites : no cough impulse

17.  Percussion
• Normal tympanic note all over the abdomen
• No shifting dullness
• Upper border of liver dullness at 5th ICS in mid clavicular line on
right side
 Auscultation
• Normal peristaltic sounds audible.

18. Cardiovascular System
Inspection
• Chest normal in shape ,size and symmetry
• Precordium normal in shape
• No engorgement of superficial veins
• Carotid pulsations visible
Palpation
• Apex beat present in left 5th intercostal space in mid clavicular line.
• No parasternal heave
• No appreciable thrill or pulsation in any area.

19. Auscultation
• Normal S1 &S2 in intensity and character in mitral, aortic and
pulmonary areas.
• Rate: 80/min, regular, No missed beats
• No pleural rub
• No murmur or added sounds heard
• No carotid bruit

20. Respiratory System
Inspection
• Normal shape, size and symmetry of chest, trachea central
• Respiratory rate-25/min regular, thoraco-abdominal, no accessory
muscles use, nasal flaring or subcostal retractions
• No visible dilatations of veins/swellings/supra-clavicular
bulge/hollowing
Palpation
• Trachea midline.
• Normal chest expansion
• No local rise in temperature, no focal tenderness

21. Percussion
• Right side: Bilateral normal resonant percussion
• Left side: normal resonant percussion, cardiac borders were demarcated
Auscultation
• Vesicular breath sounds in all 9 areas of auscultation
• No added sounds
• Vocal resonance normal

22. • Patient is having normal behavior, with normal cranial nerve & motor
examination
• Deep tendon reflexes are normal
• Plantar reflex is flexor in response.
CNS Examination

23. Summary
52 year old gentleman who is a smoker, presented
with painless, progressive jaundice associated with
high colored urine, clay colured stools and pruritus
along with significant loss of weight and appetite. On
examination, patient had icterus and a firm, non
tender lump was palpable in the right upper quadrant
of the abdomen.

24. Provisional diagnosis
 52 yr old gentleman with obstructive jaundice probably due to
malignancy.

25. Hepatic Blood Supply
 Dual blood supply
Hepatic artery- 25-30%
Portal vein- 70-75%
 Oxygen consumption
Hepatic artery- 45-50%
Portal vein- 50-55%

27. PRE-HEPATIC HEPATIC POST-HEPATIC
History • Anemia-dyspnea,
angina, weakness
• Multiple blood
transfusions
• Positive family
history
• Failure to thrive
since childhood
• H/s/o sickle cell
crisis
• Fever, pain
abdomen,
vomiting
• H/o alcohol
intake
• H/o drug intake
• H/o IV drug
abuse, high risk
behaviour
• Icterus, high
coloured urine,
clay coloured
stools
• Pruritus
• Pain abdomen,
vomiting
• Loss of weight,
appetite
• H/o passing bulky
bulky stools
Examination • Pallor,splenomeg
aly
• Abnormal facies
(thalassemia)
• Growth
retardation
• Leg ulcers,
petechiae
• Signs of liver cell
failure- palmar
erythema, spider
naevi,
gynecomastia,
testicular atrophy
• Scratch marks
• Palpable lump in
abdomen

28. PRE-HEPATIC HEPATIC POST-HEPATIC
Aminotransferases Normal Increased (maybe
normal or decreased
in advanced stages)
Normal (maybe
increased in
advanced stages)
Alkaline
phosphatase
Normal Minimal increase Marked Increased
Bilirubin Increased
unconjugated
Increased
conjugated
Increased
conjugated
Serum proteins Normal Decreased Normal (maybe
decreased in
advanced stages)
Prothrombin Time Normal Normal in early
stages and
prolonged in late
stages
Normal in early
stages & Prolonged
in advanced stages
Blood Urea
Nitrogen
Normal Normal (decreased
in advanced stages)
Normal
Sulfobromopthale Normal Retention Normal or Retention

29. PRE-HEPATIC HEPATIC POST-HEPATIC
Urine urobilinogen High Present Absent
Urine bilirubin Absent present Present
Urine Bile salts and
pigments
Absent Present Present
Stool stercobilins High Present Absent
Gamma Glutamyl
Transferase/ 5’-
nuleotidase
Normal Normal Increased

30. Investigations
 Hb: 9.8 gm%
 Total count – 6700
 Differential count:
75/23/06/02
 Platelets: 1.88 lakhs/mm3
 PT- 14 s INR: 1.3
 BT: 3’ 00”
 CT: 4’ 00”
 RBS: 82 mg/dl
 Urea: 32 mg/dl
 Creatinine: 1.0 mg/dl
 Na+: 135 mEq/l,
 K+: 3.9 mEq/l
 Cl-: 104 mEq/l

31.  LFT:
• Total Bilirubin: 9.0 (0.1 – 1.0); Direct Bilirubin: 7.3 (0.0 – 0.2) ;
Indirect Bilirubin: 1.7
• Albumin: 2.8 (3.5 – 5.0)
• Globulin: 3.2, 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, Anti-HCV: Not
detected.
 USG: Intra Hepatic Biliary radical dilatation in its entire length probably
due to stricture.

32. • ECG: Sinus rhythm. Within normal limits. Heart rate: 68/min.
• Chest X – Ray: NAD
• Upper G.I. Endoscopy: bulging growth in Periampullary region.
• C.T. Scan: Moderate dilatation of intrahepatic and common bile
ducts.

33. Concerns Due To Surgery
 Major surgery
 Long duration
 Increased blood loss and fluid shift
 Roof-top incision- postoperative analgesia
 Epidural blockade above T5- Decrease in hepatic blood
flow

34. Disease Related Concerns
 Hypoproteinemia and reduced levels of drug binding
proteins
 Altered volume of distribution and increased TBV
 Coagulopathy
 Alteration in drug metabolism and clearance
 Hypoglycemia
 Electrolyte imbalance
 Anemia, leucopenia and thrombocytopenia
 Deficiency of fat soluble vitamins( A,D,E,K)

35. Anesthetic considerations

36. 1. Patient Related
Poor nutrition
Smoking
Anaemia

37. 2. Anesthesia Related
CVS -- bradycardia and impaired contractility
Decreased PVR, vascular hyporeactivity -- blood loss and fluids
promptly restored
Prothrombin time- prolonged ,hepatic blood flow to be maintained
RENAL- Volume depleted state – perfusion should be maintained
Avoid fluid overload- GDT
GIT- Bacterial translocation, loss of barrier function
Drug metabolism – increased sensitivity to hypnotic drugs and
impaired metabolism

38. 3. Surgery Related
Major surgery- long duration with increased blood loss
and fluid shifts
Roof top incision- post op analgesia.
Epidural- blockade above T5, decrease in hepatic
blood flow
DVT prophylaxis
Prevention of hypothermia

39. Preoperative optimization
 Improve nutritional status
 Smoking cessation, incentive spirometry
 Coagulopathy-d/t Vit K def  Vit k 10 mg IV daily for 1-3 days pre-op
 Avoid pre-renal failure- Cautious use of aminoglycosides, avoid all NSAIDS.
 If Bilirubin > 8 mg% :
I/V fluid – 1-2ml/kg/hr overnight, ensure U/O - 1ml/kg/hr
Mannitol – 0.5-1 gm/kg 20% given over 20 mins 2 hrs preop or intraop
Pre-operative orders
 High risk consent, consent for post op mechanical ventilation
 Blood and blood products
 NPO orders
 Anxiolytic - short acting i.v BDZ , Anti-aspiration prophylaxis – H2 blocker,
Metoclopramide
 Morning of surgery – PT- INR, Serum electrolytes

40. ANAESTHETIC GOALS
 Minimize physiological insult to Liver & kidney
 Maintain hepatic blood flow and hepatic O2 supply –
demand relationship in liver.
 Adequate pulmonary ventilation and cardiovascular function.
 Maintain renal perfusion
 Avoid Hypotension, Sympathetic stimulation & Hypoxia
 Meticulous fluid balance and avoid fluid overload by using
Goal directed fluid therapy
 Choose appropriate anaesthetic agent - Metabolism of drugs
+ Effect on HBF
 Input and output monitoring . Blood loss replacement.

41. Intraoperative
 Induction
IV agents :
• Titrated dosage, maintain adequate MAP
• Propofol --  THBF, splanchnic vasodilation
• Ketamine(little-no effect on HBF)
Opioids :
• Metabolism is reduced, dosing intervals must be increased
• Reduced requirement – increased endogenous enkephalins

42. Inhalational :
• Decrease hepatic blood flow to variable degree
• Halothane- greatest reduction in HBF
• Iso, Sevo and Des- maintain HABR
• MAC awake reduced
Relaxants :
• Suxamethonium – prolonged - Low levels of pseudocholinesterase
• Atracurium/cis-atracurium-organ independent elimination-not
affected
• Vecuronium/rocuronium- biliary excretion – prolonged effect

43. Postoperative management
Stable: Conscious , Stable vitals, NM recovery
• Extubate and montor in HDU
• Oxygen supplement
Unstable
• Continue IPPV in Post.op. period
• Fluid & Electrolyte imbalance corrected
• CVS stability achieved.
• Hypothermia corrected.
• Urine Output 1 ml/kg/hr
• Adequate analgesia
• Blood / blood product replaced.
• Antibiotics + H2 receptor antagonist