CASE PRESENTATION

1. CASE PRESENTATION Puneet Khanna Moderator Dr. Anjolie Chhabra www.anaesthesia.co.inanaesthesia.co.in@gmail.com

2. HISTORY • RAJESHWAR SINGH , 58 yrs , M • R/O Bihar • PRESENTING COMPLAINTS • Loss of appetite for 6 months • Weight loss for 4 months • itching for 1 month • Yellow discoloration of eyes and skin for 15 days

3. HISTORY OF PRESENT ILLNESS Anorexia (6months) • Loss of appetite was progressive • More than 50% Weight loss • Significant (10 Kg in 4 months)

4. Itching (2-3 weeks) • all over body Jaundice (3 weeks) • Sudden onset (initially yellow sclera) • Progressive • continuous

5. h/o low grade fever for 8 – 10 days • h/o single episode of fever with chills • h/o passage of high coloured dark yellow urine • h/o passage of clay coloured stool

6. No h/o GI bleed or bleeding from any other site • No h/o abdominal pain • No h/o intake of medications • No h/o alcohol intake • No h/o contact with jaundiced individual • No h/o travel to hepatitis endemic area • No h/o blood or blood product transfusion

7. PAST HISTORY • H/o D.M. recently diagnosed on OHA • NO H/o any other systemic illness • No h/o previous anaesthetic exposure or surgery

8. PERSONAL HISTORY Chronic tobacco chewer • No h/o alcohol intake or drug abuse • Non vegetetarian • No alteration in bowel habbits

9. FAMILY HISTORY Non contributary No family h/o jaundice

10. GENERAL PHYSICAL EXAMINATION • Weight – 60 kg, Height – 175 cm • BMI - 19.59 • Moderate built and nourished • Yellow discolouration of sclera and all over the body (skin, nail) . Icterus • Pallor • NO edema ,clubbing ,Cyanosis, palpable lymphadenopathy

11. VITALS • Afebrile • Pulse Rate – 80 per minute, regular, normal volume, all peripheral pulses palbable, no delay • Blood pressure – 120/70 mm of Hg right arm supine • Respiratory rate – 20 per minute, regular

12. SYSTEMIC EXAMINATION ABDOMINAL EXAMINATION Inspection • Yellow discolouration of skin • No abdominal distension,dilated veins, pulsations Palpation • Soft, no tenderness • Hepatomegaly 4cm below costal margin, firm • No slenomegaly • No free fluid

13. OTHER SYSTEMS Cardiovascular system S1 and S2 heard, no murmur. Chest Normal bronchovesicular breath sounds No added sounds Nervous system Normal

14. AIRWAY EXAMINATION • Modified malampatti grade I • Mouth opening and neck movements adequate

15. Provisional diagnosis

16. INVESTIGATIONS Haemoglobin - 10 gm/dl Total leucocyte count – 13100 X10 3 / mm3 Differential count – P70 L18 E1 M5 Urea –14 mg% Creatinine – 1.1 mg% Na+ - 138 mEq/L , K+ - 3.8 mEq/L

17. Bilrubin – 4.7mg (conj – 4.4, unconj – 0.3) Total protein – 8.0gm (albumin 2.3) SGOT- 61 IU, SGPT – 29 IU Alkaline phosphatase – 903 IU Prothrombin time -12/22 sec. PT after Vit K. – 12/15 sec. ECG and Chest X ray where normal.

18. Final diagnosis • Obstructive jaundice probably malignant in origin, Childs-pughs B with no features suggestive of portal hypertension or liver failure

19. ULTRASONOGRAPHY ABDOMEN • LIVER-14 cms cranio- caudal ,moderate intrahepatic duct dilatation • GB- distended , moderate amount of sludge seenwith small calculi • CBD-12cms dilated blocked at lower end by heterogenous mass • PANCREAS-periampullary pancreas atrophied ? Distal CBD mass ? Ampullary mass

20. CECT - ABDOMEN • Moderate intrahepatic biliary dilation • CBD dilated till lower end (16 mm) • Small ill-defined soft tissue mass in ampulla of Vater (10 X 12 mm) • Gall bladder distended, no calculus. • No focal lesion in liver • Pancreatic parenchyma atrophic

21. SIDE VIEWING ENDOSCOPY • Ampulla bulky • Moderate size growth • Polypoidal ,friable , ulcerated mass lesion with oozing blood in ampullary region ? Periampullary mass

22. Anesthetic problems in Obstructive Jaundice ?

23. 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)

24. 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

25. 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

26. Age > 60 years Diabetes Hematocrit < 30% ESR > 50 Bilirubin >11mg% SGOT > 100 SGPT >100 Malignant disease Risk Factors for Postoperative Mortality Gut 1983; 24, 845-852

27. Preoperative Assessment OBJECTIVES • Assess the type and degree of liver dysfunction. • Assess effect on other system. • To ensure – post operative facilities (High risk patient).

28. 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

29. Preoperative Investigations To know the pattern of disease : ­ S. Bilirubin ­ SGOT, SGPT 90% predictive ­ alk. phosphatase

30. Preoperative Investigations To know the pattern of disease : ­ S. Bilirubin ­ SGOT, SGPT 90% predictive ­ alk. phosphatase

31. 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)

32. (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

33. 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

34. Methods of Preoperative Drainage of Bile • Percutaneous catheter • Endoprosthesis • Endoscopic papillotomy

35. Preoperative management No conclusive evidence for – • Preop percutaneous biliary drainage • Gut sterlization • Polymyxin B • Oral bile salts

36. Premedication • Anxiolytic – oral short acting BDZ • Oral H2 antagonist • Vit. K (Obst. J) – 10 mg O D X 3 day • If Bilirubin > 8 mg% – · I/V fluid – 1-2 ml/kg/hr. · Mannitol / Furosemide/Dopamine • Order morning PT / S. Electrolyte • Preop urinary catheter & CVP

37. Careful attention to perioperative hydration is the cornerstone in preserving adequate renal function. Other drugs do not confer additional protection. Hepatogastroenterology 2000;47:1691-1694

38. 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

39. Anesthetic technique • General anesthesia • Preoxygenation • Induction - Thiopentone, Etomidate – causes decrease in total hepatic blood flow ( due to dec CO) . • Propofol- increases total hepatic blood flow due to splanchnic vasodilation. Slow and titrated dose to avoid sudden hypotension • Ketamine- maintain hepatic blood flow • Avoid sympathetic stimulation during intubation as it will compromise hepatic blood flow

40. CHOICE OF DRUGS FOR MAINTENANCE OF ANESTHESIA MUSCLE RELAXATION • Succinylcholine (RSI) • Atracurium or cis atracurium (drug of choice) • Vecuronium and Pancuronium– increase in elimination half life • Vecuronium and pancuronium do not alter hepatic blood flow

41. Analgesia OPIOIDS • Protein bound • Metabolized by liver (except remifentanil) Morphine, pentazocine, meperidine, sufentanil, alfentanil  prolonged elimination half life  increased duration of action and can lead to respiratory depression

42. Anesthetic technique • Opioids – Well tolerated Morphine—ph-II reac. fentanyl(DOC) spasm of sphincter of Oddi

43. 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 –Nalaxone, NTG, Glucagon, Atropine (partial)

44. Fentanyl metabolism is not appreciably affected in patients with liver dysfunction BJA 1982;54:1267-1270 Remifentanil elimination unaltered by severe liver disease Morphine and fentanyl causes splanchnic vasodilation improving hepatic oxygen delivery Anesthesia and analgesia 1985; 64(6):577-584

45. Anesthetic technique Volatile Anesthetics • Useful & well tolerated • Disadv- CVS instability  vasodilation perf. Press.  blood velocity  oxygen extraction  HBF & oxygen supply • Isoflurane—best maint. of HBF & oxygen

46. Inhalational agents and hepatic blood flow

47. Anesthetic technique IPPV – - Maintain eucapnia - Liver low pr.tissue bed - Avoid large VT & high airway pressures

48. Anesthetic technique • Maintenance of BV and Renal function • Mannitol • Frusemide • Dopamine • Adequate blood/component replacement

49. REGIONAL ANESTHESIA AS SUPPLEMENT TO G.A. • EPIDURAL ANESTHESIA • SUBARACHNOID MORPHINE • COELIAC PLEXUS BLOCK • CONCERNS– Coagulopathy, Hypotension • Duaration of action of xylocaine

50. Intra Operative Monitoring • ECG, Pulse Oximetery, NIBP • EtCO2 • Urine output • Core temp • NMJ monitoring • Blood loss Biochemical B.Sugar,ABG S.Electrolytes Hematological Hb,PT,,PTTK,TEG Long and extensive Cvp, Intra arterial