Obstructive jaundice Anesthesia Management
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Transcript of Obstructive jaundice Anesthesia Management
Obs. JObs. J
Obstructive Jaundice – Whipple’s Obstructive Jaundice – Whipple’s OperationOperation Anesthetic ManagementAnesthetic Management
Munisha AgarwalMunisha Agarwal
Professor Professor Deptt. of Anaesthesiology Deptt. of Anaesthesiology
& Intensive Care& Intensive Care
L N Hospital & Maulana L N Hospital & Maulana
Azad Medical College DelhiAzad Medical College Delhi
Obs. JObs. J
Obstructive JaundiceObstructive Jaundice
Physiological functions of Physiological functions of Liver ?Liver ?
Obst. JObst. J
Physiological functions of LiverPhysiological functions of Liver
Glucose HomeostasisGlucose Homeostasis Fat MetabolismFat Metabolism Protein SynthesisProtein Synthesis Drug & Hormone MetabolismDrug & Hormone Metabolism Bilirubin formation &excretionBilirubin formation &excretion Anti bacterial actionAnti bacterial action Blood ReservoirBlood Reservoir
Obst. JObst. J
Glucose homeostasisGlucose homeostasis
Glucose Glucose hepatocytes hepatocytes glycogen glycogen glucoseglucose
lactatelactate
glycerol glycerol
AA AA
Obst. JObst. J
Glucose HomeostasisGlucose Homeostasis
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))
- reduction & hydrolysis (L.A)- reduction & hydrolysis (L.A)
phase II - - conjugation, glucuronidation,, glucuronidation,
sulphation, methylation &sulphation, methylation &
acetylationacetylation
- UDGT ( Bilirubin, morphine, - UDGT ( Bilirubin, morphine,
aminophylline)aminophylline)
Conjugation reaction?Conjugation reaction?
Obst. JObst. J
Drug metabolismDrug metabolism
Clearance of drugs from plasmaClearance of drugs from plasma
High HE ratio ~ Hepatic Blood Flow High HE ratio ~ Hepatic Blood Flow (HBF) (HBF) Lidocain, Pethidine, Lidocain, Pethidine, FentanylFentanyl
low HE ratio ~microsomal enzymeslow HE ratio ~microsomal enzymes
~protein binding ~protein binding diazepam, thiop, pancuroniumdiazepam, thiop, pancuronium
Obst. JObst. J
Drug metabolismDrug metabolism
Anesthetic implicationsAnesthetic implications Chronic liver disease Chronic liver disease drug drug
metabolism metabolism d/t d/t - - ed no. of ed no. of hepatocyteshepatocytes
- HBF- HBF Repeated injection Repeated injection cumulative effect cumulative effect Volatile anesth. Agents Volatile anesth. Agents ed clearance ed clearance
of drugsof drugs
Obst. JObst. J
Bilirubin formation & excretionBilirubin formation & excretion
Daily prod 250—350mg/dDaily prod 250—350mg/d Interpretation of plasma Interpretation of plasma
& urine bilirubin& urine bilirubin Categories of liver Categories of liver
dysfunctiondysfunction
1 unit BT ?1 unit BT ?
Obst. JObst. J
Blood ReservoirBlood Reservoir
10% of total blood volume 10% of total blood volume Available for Auto transfusion into Available for Auto transfusion into
central circulation central circulation
Obst. JObst. J
Hepatic Blood SupplyHepatic Blood Supply
Unique ?Unique ?
Obst. JObst. J
Hepatic Blood SupplyHepatic Blood Supply
25% to 30% of CO25% to 30% of CO Dual supply Dual supply
Portal V Portal V (75%) 85% saturated(75%) 85% saturated
Hepatic A Hepatic A (25%) 95%saturated(25%) 95%saturated
2/3 of oxygen used by liver2/3 of oxygen used by liver
Obst. JObst. J
Control of Liver Blood FlowControl of Liver Blood Flow
INTRINSICINTRINSIC AUTOREGULATIONAUTOREGULATION
- Hepatic artery-80 mmHg- Hepatic artery-80 mmHg
- Portal vein – flow from spleen, - Portal vein – flow from spleen, intestineintestine
- resistance to vascular bed- resistance to vascular bed
Hepatic Arterial Buffer response.Hepatic Arterial Buffer response.
Extrinsic ?Extrinsic ?
Obst. JObst. J
Control of Liver Blood FlowControl of Liver Blood Flow EXTRINSICEXTRINSIC
Increase HBFIncrease HBF Acute hepatitisAcute hepatitis Supine postureSupine posture HypercapniaHypercapnia DrugsDrugs ββadrenostimulationadrenostimulation
Decrease HBFDecrease HBF
HypoxiaHypoxia Hepatic cirrhosisHepatic cirrhosis Upright postureUpright posture Hypocapnia/IPPV/PEEPHypocapnia/IPPV/PEEP DrugsDrugs ββadrenoreceptor adrenoreceptor
blockade/ blockade/ αα agonist agonist Ganglion blockadeGanglion blockade Anaesthetic agentAnaesthetic agent
Obst. JObst. J
Liver Function TestsLiver Function Tests
Non specificNon specific Large hepatic reserveLarge hepatic reserve
LFT ?LFT ?
Obst. JObst. J
Liver Function TestsLiver Function Tests S. BilirubinS. Bilirubin (T) - 0.3—1.1mg% (T) - 0.3—1.1mg% {(I) 0.2-0.7mg%, (D)0.1—0.4mg%){(I) 0.2-0.7mg%, (D)0.1—0.4mg%)
TransaminasesTransaminases—SGOT/SGPT/LDH—SGOT/SGPT/LDH hepatocyte damage hypoxia/drugs/viruseshepatocyte damage hypoxia/drugs/viruses
Extrahepatic—heart/lungs/skeletal msExtrahepatic—heart/lungs/skeletal msMarkedMarked (3x)-ac. Hep damage (3x)-ac. Hep damage
Alkaline phoshphataseAlkaline phoshphatase - bile duct cells - bile duct cells slight obstruction (3x)slight obstruction (3x) bone –extrahep sourcebone –extrahep source S. AlbuminS. Albumin 5- Nucleotidase5- Nucleotidase GGTGGTPrehepatic / Hepatic / Posthepatic J ?Prehepatic / Hepatic / Posthepatic J ?
Obst. JObst. J
Hepatic Hepatic dysfunctiodysfunctionn
BilirubinBilirubin TransaminaTransaminase enzymese enzyme
AlkalineAlkalinephosph.phosph.
CausesCauses
Pre Pre hepatichepatic
UnconjugUnconjug
ated ated (indirect)(indirect)
NormalNormal NormalNormal Hemolysis/Hemolysis/
hematoma hematoma resorp./resorp./
bilirubin bilirubin overload-overload-BTBT
IntrahepatiIntrahepatic(hepatocec(hepatocellular)llular)
ConjugatConjugated(direct)ed(direct)
elevatedelevated Normal to Slightly
Viral/Viral/drugs/drugs/sepsis/sepsis/hypoxia/hypoxia/cirrhosiscirrhosis
PosthepatiPosthepaticc
(cholestati(cholestatic)c)
conjugateconjugatedd
Nomal to Nomal to slightly slightly eded
(2x)(2x) Stones,Stones,
Sepsis, Sepsis, tumortumor
Obst. JObst. J
SPECTRUM OF LIVER DISEASESPECTRUM OF LIVER DISEASE
Parenchymal-Acute & Chronic HepatitisParenchymal-Acute & Chronic Hepatitis
-Hepatic Cirrhosis (-Hepatic Cirrhosis (++ portal portal
hypertension)hypertension) Cholestatic -Intrahepatic – viral hepatitis Cholestatic -Intrahepatic – viral hepatitis
– – drug induceddrug induced
-Extrahepatic (Obstructive jaundice)-Extrahepatic (Obstructive jaundice)
– – Calculi, stricture, growth.Calculi, stricture, growth.Parenchymal disease ultimately possesses an Parenchymal disease ultimately possesses an obstructive component & Obstructive disease obstructive component & Obstructive disease produces cellular dysfunction.produces cellular dysfunction.
Clinical Hallmarks ?
Obst. JObst. J
Signs &SymptomsSigns &Symptoms
Prog sev jaundiceProg sev jaundice Dark urineDark urine Clay coloured stoolsClay coloured stools PruritisPruritis High fever+ chillsHigh fever+ chills
Biochemical hallmarksBiochemical hallmarks
Obst. JObst. J
Obstructive JaundiceObstructive Jaundice
Primary mechanism- Obst. of E.H. Primary mechanism- Obst. of E.H. bile duct.bile duct.
Bile duct pressureBile duct pressure --
Normal – 10-15 cm H2ONormal – 10-15 cm H2O
> 15 cm > 15 cm →→ bile flow bile flow decreasesdecreases
> 30 cm > 30 cm →→ bile flow stops bile flow stops
Obst. JObst. J
Pathophysiological consequencesPathophysiological consequences
CHOLESTASIS
Retention of bile solutesIn liver
Hepatocyte func Cyto-450 –metab
Protein synth-alb - clotting factors
Bile constituents in serum conju. Bilirubin
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
Systemic Alterations – CVS ?Systemic Alterations – CVS ?
Obst. JObst. J
Systemic alterationsSystemic alterations Circulatory homeostasisCirculatory homeostasis
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
Hypotension & circulatory collapseHypotension & circulatory collapse
Obst. JObst. J
Renal systemRenal system
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
urine( 10mmol/l)urine( 10mmol/l) Functional changeFunctional change Normal renal blood flowNormal renal blood flow
Treatment : Prevention-identify high Treatment : Prevention-identify high risk patientsrisk patients
Hepatorenal Hepatorenal SyndromeSyndrome
Obst. JObst. J
Systemic alterationsSystemic alterations
Coagulopathy(low grade DIC)Coagulopathy(low grade DIC)
Impaired platelet functionImpaired platelet function
FDP---inhibition of fibrinolysisFDP---inhibition of fibrinolysis
EndotoxinsEndotoxins Hm gastritis & stress ulcersHm gastritis & stress ulcers Impaired wound healing Impaired wound healing
Obst. JObst. J
Anesthetic problems in Anesthetic problems in Obstructive Jaundice ?Obstructive Jaundice ?
Obst. JObst. J
PROBLEMSPROBLEMSDUE TO DYSFUNCTION OF LIVER ITSELF :DUE TO DYSFUNCTION OF LIVER ITSELF :- Low serum proteins- Low serum proteins- Coagulopathy- Coagulopathy- Drug metabolism and disposition- Drug metabolism and disposition- Metabolic derangement - Hypoglycemia- Metabolic derangement - Hypoglycemia - Electrolyte imbalance- Electrolyte imbalance- Haematological - Anaemia- Haematological - Anaemia
– – ThrombocytopeniaThrombocytopenia – – LeucopeniaLeucopenia – – DIC DIC
- Deficiency of fat soluble vitamins (A, D, E, K)- Deficiency of fat soluble vitamins (A, D, E, K)- Increased serum cholesterol (atheromatous - Increased serum cholesterol (atheromatous
changes)changes)
Obst. JObst. J
PROBLEMSPROBLEMS
DUE TO INVOLVEMENT OF OTHERDUE TO INVOLVEMENT OF OTHER SYSTEMSSYSTEMS
CVS– TBV CVS– TBV , PVR , PVR , , Circulatory collapseCirculatory collapse Renal - pre renal azotemiaRenal - pre renal azotemia
- Hepatorenal failure - Hepatorenal failure GIT - Hm gastritis & stress ulcersGIT - Hm gastritis & stress ulcers Resp.–Resp.– Arterial Hypoxemia Arterial Hypoxemia
- vulnerability to pulmonary infection- vulnerability to pulmonary infection CNS – Hepatic encephalopathyCNS – Hepatic encephalopathy
Problems related to surgery ?Problems related to surgery ?
Obst. JObst. J
Problems related to surgeryProblems related to surgery
Whipple’s procedure---Carc. Head of pancWhipple’s procedure---Carc. Head of panc Distal gastrectomy,PJ, HJ, GJDistal gastrectomy,PJ, HJ, GJ Major surgery---long durationMajor surgery---long duration Increased blood loss/fluid shiftsIncreased blood loss/fluid shifts Wide incision---Roof top—warrants good Wide incision---Roof top—warrants good
postoperative analgesiapostoperative analgesia Extensive monitoring reqd for favourable Extensive monitoring reqd for favourable
outcome outcome
Obst. JObst. J
Risk FactorsRisk Factors
Age > 60yrsAge > 60yrs Albumin < 30gm%Albumin < 30gm% Preop. renal dysfunctionPreop. renal dysfunction Long standing biliary obstruction Long standing biliary obstruction
infection infection sepsis sepsis Weight lossWeight loss
Serum creatinine & Sepsis—prognostic Serum creatinine & Sepsis—prognostic factorsfactors
Periop CVS collapse & renal failurePeriop CVS collapse & renal failure
Obst. JObst. J
Preoperative AssessmentPreoperative Assessment
OBJECTIVESOBJECTIVES
Assess the type and degree of liver Assess the type and degree of liver dysfunction.dysfunction.
Assess effect on other system.Assess effect on other system. To ensure – post operative facilities (High To ensure – post operative facilities (High
risk patient).risk patient).
Obst. JObst. J
Preoperative AssessmentPreoperative Assessment
HistoryHistory Clinical examinationClinical examination Investigations ???Investigations ???
Unexplained jaundice of 4wks duration or longer Unexplained jaundice of 4wks duration or longer
will prove to be caused by obstruction in nearly will prove to be caused by obstruction in nearly
75% patients75% patients
Blumgart LBlumgart L
Obst. JObst. J
Preoperative InvestigationsPreoperative Investigations
To know the pattern of disease :To know the pattern of disease :
S. Bilirubin S. Bilirubin
SGOT, SGPT SGOT, SGPT 90% predictive90% predictive
alk. phosphatase alk. phosphatase
Obst. JObst. J
Preoperative InvestigationsPreoperative Investigations
To judge the synthetic ability of liverTo judge the synthetic ability of liver
Serum albumin–Serum albumin– < 2·5 gm% - severe < 2·5 gm% - severe damagedamage
Albumin/globulin ratioAlbumin/globulin ratio – reversed.– reversed. Prothrombin timeProthrombin time –> 1·5 sec. Over –> 1·5 sec. Over
controlcontrol
– – INR - > 1.3INR - > 1.3
(D/D – Par entral Vit. K – Obst. (D/D – Par entral Vit. K – Obst. Jaundice)Jaundice)
Obst. JObst. J
To assess general condition of patientTo assess general condition of patient
(i) Haematological(i) Haematological · · HbHb
TLC, DLCTLC, DLC
Platelet CountPlatelet CountClotting factors Clotting factors
((PTPT, PTTK) , PTTK)
BTBT
(ii)Cardiorespiratory(ii)Cardiorespiratory
Chest X-rayChest X-ray
ECGECG
Blood gasesBlood gases
(iii) Metabolic-(iii) Metabolic-
Serum proteinsSerum proteins
Serum glucoseSerum glucose
ElectrolyteElectrolyte
Urea / Creatinine Urea / Creatinine
Urinary-Urea/ Creatinine Urinary-Urea/ Creatinine
-Electrolyte -Electrolyte
(iv)(iv) Hepatic imagingHepatic imaging
(v)(v) Microbiological – Microbiological –
-- CultureCulture
-- 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% –
· I/V fluid – 1-2 ml/kg/hr.· I/V fluid – 1-2 ml/kg/hr.
· Mannitol – 100 ml of 20% 2 hrs · Mannitol – 100 ml of 20% 2 hrs preop.preop.
Order morning PT / S. ElectrolyteOrder morning PT / S. Electrolyte Preop urinary catheter & CVPPreop urinary catheter & CVP
Obst. JObst. J
Anaesthetic ManagementAnaesthetic Management
General ConsiderationsGeneral ConsiderationsMinimize physiological insult to liver & kidneyMinimize physiological insult to liver & kidney Maintain O2 supply – demand relationship in Maintain O2 supply – demand relationship in
liver.liver. →→Adequate pulmonary ventilation and Adequate pulmonary ventilation and
cardiovascular fn.cardiovascular fn. Maintain renal perfusionMaintain renal perfusion
→→Avoid Hypotension, hypoproteinemia & Avoid Hypotension, hypoproteinemia & Hypoxia Hypoxia →→ meticulous fluid balancemeticulous fluid balance
Choose appropriate anaesthetic agentChoose appropriate anaesthetic agent Metabolism of drugs + Effect on HBF.Metabolism of drugs + Effect on HBF.
Induction ?Induction ?
Obst. JObst. J
Anesthetic techniqueAnesthetic technique
General anesthesiaGeneral anesthesia PreoxygenationPreoxygenation Induction - Induction - ThiopentoneThiopentone PropofolPropofol Muscle relaxant –Muscle relaxant –
SuxamethoniumSuxamethonium Vecuronium 0.15mg/kg Vecuronium 0.15mg/kg
Rocuronium0.6mg/kgRocuronium0.6mg/kgAtracurium(DOC)Atracurium(DOC)
Opioids ?Opioids ?
Obst. JObst. J
Anesthetic techniqueAnesthetic technique
Opioids – Opioids – Well toleratedWell tolerated
smaller dosessmaller doses
Morphine—ph-II reac.Morphine—ph-II reac.
fentanyl(DOC)fentanyl(DOC)
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
perf. Press. perf. Press. blood velocity blood velocity oxygen oxygen extraction extraction HBF & oxygen supply HBF & oxygen supply
Isoflurane—best maint. of HBF & oxygenIsoflurane—best maint. of HBF & oxygen
IPPV ?IPPV ?
Obst. JObst. J
Anesthetic techniqueAnesthetic technique
IPPV –IPPV –
- Maintain eucapnia- Maintain eucapnia
- Liver low pr.tissue bed- Liver low pr.tissue bed
- Avoid large V- Avoid large VT T & high airway & high airway pressures pressures
Obst. JObst. J
Anesthetic techniqueAnesthetic technique
Maintenance of BV and Renal Maintenance of BV and Renal functionfunction
MannitolMannitol FrusemideFrusemide DopamineDopamine Adequate blood/component Adequate blood/component
replacementreplacement
Obst. JObst. J
MonitoringMonitoring
BP,HR,SpO2BP,HR,SpO2 EtCO2EtCO2 CVPCVP Urine outputUrine output Core tempCore temp NMJ monitoringNMJ monitoring Blood lossBlood loss
BiochemicalBiochemicalB.Sugar,ABGB.Sugar,ABGS.ElectrolytesS.Electrolytes
HematologicalHematologicalHb,PT,,PTTK,TEGHb,PT,,PTTK,TEG
Obst. JObst. J
Postoperative managementPostoperative management
All well All well Extubate ExtubateUnstable Unstable
-- Continue IPPV in Post.op. Continue IPPV in Post.op. periodperiod
-- Fluid & Electrolyte imbalanceFluid & Electrolyte imbalance correctedcorrected
-- CVS stability achieved.CVS stability achieved.-- Hypothermia corrected.Hypothermia corrected.-- Urine Output 1 ml/kg/hr.Urine Output 1 ml/kg/hr.
Adequate analgesiaAdequate analgesia (Small doses) (Small doses)Blood / blood product replaced.Blood / blood product replaced.Antibiotics + H2 receptor antagonistAntibiotics + H2 receptor antagonist
Obst. JObst. JThank YouThank You