This document discusses obstructive jaundice and Whipple's operation. It provides information on: 1) The physiological functions of the liver including glucose homeostasis, fat and protein metabolism, drug and hormone metabolism, bilirubin formation and excretion, and its role as a blood reservoir. 2) How obstructive jaundice affects liver function and can lead to endotoxemia, systemic alterations to circulatory homeostasis like hypotension, and effects on the renal system like hypoperfusion. 3) Considerations for anesthetic management for a patient undergoing Whipple's operation to address obstructive jaundice, given the liver's role and how its dysfunction impacts other organ systems.

1. Obs. JObs. J
Obstructive Jaundice – Whipple’s OperationObstructive Jaundice – Whipple’s Operation
Anesthetic ManagementAnesthetic Management
Munisha AgarwalMunisha Agarwal
ProfessorProfessor
Deptt. of AnaesthesiologyDeptt. of Anaesthesiology
& Intensive Care& Intensive Care
L N Hospital & MaulanaL N Hospital & Maulana
Azad Medical College DelhiAzad Medical College Delhi

2. Obs. JObs. J
Obstructive JaundiceObstructive Jaundice
Physiological functions of Liver ?Physiological functions of Liver ?

3. Obst. 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

4. Obst. J
Glucose homeostasisGlucose homeostasis
GlucoseGlucose hepatocyteshepatocytes glycogenglycogen glucoseglucose
lactatelactate
glycerolglycerol
AAAA

5. Obst. 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

6. Obst. J
Fat metabolismFat metabolism
 Synthesis of lipo-proteins & cholesterolSynthesis of lipo-proteins & cholesterol
 Oxidation of FA to ketone bodiesOxidation of FA to ketone bodies

7. Obst. 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 (3.5-5.5gm%)- Albumin daily prod. 10—15g/d (3.5-5.5gm%)
- liver disease- liver disease ↓↓ albalb ↑↑ globglob
Albumin ?Albumin ?

8. Obst. J
Protein synthesisProtein synthesis
 Plasma O. P.Plasma O. P.
 Drug bindingDrug binding
 CoagulationCoagulation
 HydrolysisHydrolysis

9. Obst. J
Drug bindingDrug binding
 Drugs reversibly combine with AlbuminDrugs reversibly combine with Albumin
 ↓↓ albuminalbumin ↓↓ binding sitesbinding sites ↑↑ free drugfree drug
 Albumin < 2.5gm%Albumin < 2.5gm%
 Acute Hepatic dysfunction ?Acute Hepatic dysfunction ?
Coagulation ?Coagulation ?

10. Obst. J
Drug bindingDrug binding
 Acute hepatic dysfunction - drug bindingAcute hepatic dysfunction - drug binding
not affectednot 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?

11. Obst. J
CoagulationCoagulation
 Prothrombin, fibrinogenProthrombin, fibrinogen
 Factor V, VII, IX, X ( except VIII)Factor V, VII, IX, X ( except VIII)
Deranged Coagulation ?Deranged Coagulation ?

12. Obst. J
CoagulationCoagulation
Deranged coagulationDeranged coagulation
 ↓↓ed synthesis of Clotting factorsed synthesis of Clotting factors
 ↑↑ed PT Vit. K deficiency d/t biliaryed PT Vit. K deficiency d/t biliary
obstructionobstruction absence of bile saltsabsence of bile salts
 ThrombocytopeniaThrombocytopenia
 ↑↑ed Fibrinolysinsed Fibrinolysins

13. Obst. J
CoagulationCoagulation
 Evaluate PT/ PTTK/ BTEvaluate PT/ PTTK/ BT
 LFT grossly deranged before coagulationLFT grossly deranged before coagulation
abnormalities appearabnormalities appear
 20%--30% activity required for normal20%--30% activity required for normal
coagulationcoagulation
 TT1/2 of1/2 of clotting factors produced in liver isclotting factors produced in liver is
very short (in hrs)very short (in hrs)
 Ac. Hep dysfunctionAc. Hep dysfunction  Coag. Abn.Coag. Abn.

14. Obst. 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)

15. Obst. J
Drug metabolismDrug metabolism
Clearance of drugs from plasmaClearance of drugs from plasma
High HE ratio ~ Hepatic Blood Flow (HBF)High HE ratio ~ Hepatic Blood Flow (HBF)
Lidocain, Pethidine, FentanylLidocain, Pethidine, Fentanyl
low HE ratio ~microsomal enzymeslow HE ratio ~microsomal enzymes
~protein binding~protein binding
diazepam, thiop, pancuroniumdiazepam, thiop, pancuronium

16. Obst. J
Drug metabolismDrug metabolism
Anesthetic implicationsAnesthetic implications
 Chronic liver diseaseChronic liver disease ↓↓ drug metabolismdrug metabolism
d/td/t -- ↓↓ed no. of hepatocytesed no. of hepatocytes
- HBF- HBF
 Repeated injectionRepeated injection  cumulative effectcumulative effect
 Volatile anesth. AgentsVolatile anesth. Agents  ↓↓ed clearanceed clearance
of drugsof drugs

17. Obst. J
Bilirubin formation & excretionBilirubin formation & excretion
 Daily prod 250—350mg/dDaily prod 250—350mg/d
 Interpretation of plasma &Interpretation of plasma &
urine bilirubinurine bilirubin
 Categories of liverCategories of liver
dysfunctiondysfunction
1 unit BT ?1 unit BT ?

18. Obst. J
Blood ReservoirBlood Reservoir
 10% of total blood volume10% of total blood volume
 Available for Auto transfusion into centralAvailable for Auto transfusion into central
circulationcirculation

19. Obst. J
Hepatic Blood SupplyHepatic Blood Supply
 Unique ?Unique ?

20. Obst. J
Hepatic Blood SupplyHepatic Blood Supply
 25% to 30% of CO25% to 30% of CO
 Dual supplyDual supply
Portal VPortal V (75%) 85% saturated(75%) 85% saturated
Hepatic AHepatic A (25%) 95%saturated(25%) 95%saturated
2/3 of oxygen used by liver2/3 of oxygen used by liver

21. Obst. 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, intestine- Portal vein – flow from spleen, intestine
- resistance to vascular bed- resistance to vascular bed
 Hepatic Arterial Buffer response.Hepatic Arterial Buffer response.
Extrinsic ?Extrinsic ?

22. Obst. 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 blockade/adrenoreceptor blockade/
αα agonistagonist
 Ganglion blockadeGanglion blockade
 Anaesthetic agentAnaesthetic agent

23. Obst. J
Liver Function TestsLiver Function Tests
 Non specificNon specific
 Large hepatic reserveLarge hepatic reserve
LFT ?LFT ?

24. Obst. 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 ms
MarkedMarked↑↑ (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
 GGTGGT
Prehepatic / Hepatic / Posthepatic J ?Prehepatic / Hepatic / Posthepatic J ?

25. Obst. J
HepaticHepatic
dysfunctiondysfunction
BilirubinBilirubin TransaminasTransaminas
e enzymee enzyme
AlkalinepAlkalinep
hosph.hosph.
CausesCauses
Pre hepaticPre hepatic UnconjugUnconjug
atedated
(indirect)(indirect)
NormalNormal NormalNormal Hemolysis/Hemolysis/
hematomahematoma
resorp./resorp./
bilirubinbilirubin
overload-BToverload-BT
Intrahepatic(Intrahepatic(
hepatocellulhepatocellul
ar)ar)
ConjugateConjugate
d(direct)d(direct)
elevatedelevated Normal to
Slightly ↑
Viral/drugs/sViral/drugs/s
epsis/hypoxiepsis/hypoxi
a/cirrhosisa/cirrhosis
PosthepaticPosthepatic
(cholestatic)(cholestatic)
conjugatedconjugated Nomal toNomal to
slightlyslightly ↑↑eded
↑↑ (2x)(2x) Stones,Stones,
Sepsis,Sepsis,
tumortumor

26. Obst. J
SPECTRUM OF LIVER DISEASESPECTRUM OF LIVER DISEASE
 Parenchymal-Acute & Chronic HepatitisParenchymal-Acute & Chronic Hepatitis
-Hepatic Cirrhosis (-Hepatic Cirrhosis (++ portalportal
hypertension)hypertension)
 Cholestatic -Intrahepatic – viral hepatitisCholestatic -Intrahepatic – viral hepatitis
–– drug induceddrug induced
-Extrahepatic (Obstructive jaundice)-Extrahepatic (Obstructive jaundice)
–– Calculi, stricture, growth.Calculi, stricture, growth.
Parenchymal disease ultimately possesses anParenchymal disease ultimately possesses an
obstructive component & Obstructive disease producesobstructive component & Obstructive disease produces
cellular dysfunction.cellular dysfunction.
Clinical Hallmarks ?

27. Obst. 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

28. Obst. J
Obstructive JaundiceObstructive Jaundice
 Primary mechanism- Obst. of E.H. bilePrimary mechanism- Obst. of E.H. bile
duct.duct.
 Bile duct pressureBile duct pressure --
Normal – 10-15 cm H2ONormal – 10-15 cm H2O
> 15 cm> 15 cm →→ bile flow decreasesbile flow decreases
> 30 cm> 30 cm →→ bile flow stopsbile flow stops

29. Obst. J
Pathophysiological consequencesPathophysiological consequences
CHOLESTASIS
Retention of bile solutes
In liver
Hepatocyte func ↓
Cyto-450 –metab
Protein synth-alb ↓
- clotting factors ↓
Bile constituents in serum
↑conju. Bilirubin
Serum bile acids—pruritus
Hypercholesterolemia-
Ahteromas, Xanthomas
Systemic effect-CVS/renal/ GIT
Absence of bile in intestine
Malabsorp steatorrhoea
↓ Vitamin A,D, E, K
Escape of endotoxins into
portal blood
Bile Acids are potent toxins

30. Obst. J
Endotoxemia in obstructive jaundiceEndotoxemia in obstructive jaundice
Bile salts are surfactants----disrupt endotoxins
Causes of endotoxemiaCauses of endotoxemia
 Absence of bile in intestineAbsence of bile in intestine →→ intest.bact. Floraintest.bact. Flora
 Breakdown of GI mucos. barrier-Breakdown of GI mucos. barrier- bact. translocationbact. translocation
 ↓↓Hepatic RES functionHepatic RES function →→ ↓↓clearance of endotoxinsclearance of endotoxins
Systemic Alterations – CVS ?Systemic Alterations – CVS ?

31. Obst. J
Systemic alterationsSystemic alterations
 Circulatory homeostasisCirculatory homeostasis
CHOLEMIACHOLEMIA →→ ●● vasodepressor effect on BVsvasodepressor effect on BVs
●● cardiodepressorcardiodepressor →→ LVFLVF
●● ↓↓ PVRPVR →→ ↓↓ BPBP →→ sympathsympath ++
renal & cerebral vasoconstrictionrenal & cerebral vasoconstriction
●● redistribution of TBVredistribution of TBV →→ trappingtrapping
of blood in splanc. Circulationof blood in splanc. Circulation →→
↓↓ effective BVeffective BV
●● NO - insensitive to vasoconstrictorsNO - insensitive to vasoconstrictors
↑↑ Hypotension & circulatory collapseHypotension & circulatory collapse

32. Obst. 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

33. Obst. J
Renal SystemRenal System
Renal vasoconstriction
Arterial hypotension
Nephrotoxic bile salt
& pigments
Endotoxins &
Inflammatory mediators
• Acute Renal FailureAcute Renal Failure
• Hepatorenal SyndromeHepatorenal Syndrome

34. Obst. J
Renal systemRenal system
 OliguriaOliguria
 Inability to excrete Na in urine( 10mmol/l)Inability to excrete Na in urine( 10mmol/l)
 Functional changeFunctional change
 Normal renal blood flowNormal renal blood flow
 Treatment : Prevention-identify high riskTreatment : Prevention-identify high risk
patientspatients
Hepatorenal SyndromeHepatorenal Syndrome

35. Obst. 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 healingImpaired wound healing

36. Obst. J
Anesthetic problems inAnesthetic problems in
Obstructive Jaundice ?Obstructive Jaundice ?

37. Obst. J
PROBLEMSPROBLEMS
DUE 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
–– DICDIC
- Deficiency of fat soluble vitamins (A, D, E, K)- Deficiency of fat soluble vitamins (A, D, E, K)
- Increased serum cholesterol (atheromatous changes)- Increased serum cholesterol (atheromatous changes)

38. Obst. J
PROBLEMSPROBLEMS
DUE TO INVOLVEMENT OF OTHERDUE TO INVOLVEMENT OF OTHER
SYSTEMSSYSTEMS
 CVS– TBVCVS– 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 HypoxemiaArterial Hypoxemia
- vulnerability to pulmonary infection- vulnerability to pulmonary infection
 CNS – Hepatic encephalopathyCNS – Hepatic encephalopathy
Problems related to surgery ?Problems related to surgery ?

39. Obst. 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 goodWide incision---Roof top—warrants good
postoperative analgesiapostoperative analgesia
 Extensive monitoring reqd for favourableExtensive monitoring reqd for favourable
outcomeoutcome

40. Obst. J
Risk FactorsRisk Factors
 Age > 60yrsAge > 60yrs
 Albumin < 30gm%Albumin < 30gm%
 Preop. renal dysfunctionPreop. renal dysfunction
 Long standing biliary obstructionLong standing biliary obstruction →→ infectioninfection →→
sepsissepsis
 Weight lossWeight loss
↑↑Serum creatinine & Sepsis—prognostic factorsSerum creatinine & Sepsis—prognostic factors
↑↑Periop CVS collapse & renal failurePeriop CVS collapse & renal failure

41. Obst. J
Preoperative AssessmentPreoperative Assessment
OBJECTIVESOBJECTIVES
 Assess the type and degree of liverAssess the type and degree of liver
dysfunction.dysfunction.
 Assess effect on other system.Assess effect on other system.
 To ensure – post operative facilities (High riskTo ensure – post operative facilities (High risk
patient).patient).

42. Obst. J
Preoperative AssessmentPreoperative Assessment
 HistoryHistory
 Clinical examinationClinical examination
 Investigations ???Investigations ???
Unexplained jaundice of 4wks duration or longerUnexplained jaundice of 4wks duration or longer
will prove to be caused by obstruction in nearlywill prove to be caused by obstruction in nearly
75% patients75% patients
Blumgart LBlumgart L

43. Obst. 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

44. Obst. 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 damage< 2·5 gm% - severe damage
 Albumin/globulin ratioAlbumin/globulin ratio – reversed.– reversed.
 Prothrombin timeProthrombin time –> 1·5 sec. Over control–> 1·5 sec. Over control
–– INR - > 1.3INR - > 1.3
(D/D – Par entral Vit. K – Obst. Jaundice)(D/D – Par entral Vit. K – Obst. Jaundice)

45. Obst. J
To assess general condition of patientTo assess general condition of patient
(i) Haematological(i) Haematological ··
HbHb
TLC, DLCTLC, DLC
Platelet CountPlatelet Count
Clotting factorsClotting 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 / CreatinineUrea / Creatinine
Urinary-Urea/ CreatinineUrinary-Urea/ Creatinine
-Electrolyte-Electrolyte
(iv)(iv) Hepatic imagingHepatic imaging
(v)(v) Microbiological –Microbiological –
-- CultureCulture
-- Hep. B markerHep. B marker
-- Viral antibodiesViral antibodies

46. Obst. 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
 CorrectCorrect
Anaemia/Coagulation/hypoalbuminemiaAnaemia/Coagulation/hypoalbuminemia
 Avoid all NSAIDSAvoid all NSAIDS
 I/V saline & mannitol pre & postopI/V saline & mannitol pre & postop

47. Obst. 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 ?

48. Obst. 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 preop.· Mannitol – 100 ml of 20% 2 hrs preop.
 Order morning PT / S. ElectrolyteOrder morning PT / S. Electrolyte
 Preop urinary catheter & CVPPreop urinary catheter & CVP

49. Obst. J
Anaesthetic ManagementAnaesthetic Management
General ConsiderationsGeneral Considerations
Minimize physiological insult to liver & kidneyMinimize physiological insult to liver & kidney
 Maintain O2 supply – demand relationship in liver.Maintain O2 supply – demand relationship in liver.
→→Adequate pulmonary ventilation andAdequate pulmonary ventilation and
cardiovascular fn.cardiovascular fn.
 Maintain renal perfusionMaintain renal perfusion
→→Avoid Hypotension, hypoproteinemia & HypoxiaAvoid Hypotension, hypoproteinemia & 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 ?

50. Obst. J
Anesthetic techniqueAnesthetic technique
 General anesthesiaGeneral anesthesia
 PreoxygenationPreoxygenation
 Induction -Induction - ThiopentoneThiopentone
PropofolPropofol
 Muscle relaxant –Muscle relaxant –
SuxamethoniumSuxamethonium
Vecuronium 0.15mg/kgVecuronium 0.15mg/kg
Rocuronium0.6mg/kgRocuronium0.6mg/kg
Atracurium(DOC)Atracurium(DOC)
 Opioids ?Opioids ?

51. Obst. 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

52. Obst. J
Anesthetic techniqueAnesthetic technique
Spasm of sphincter of OddiSpasm of sphincter of Oddi
 Interpretation of operativeInterpretation 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 systemIntraop manipulation of BD system →→
spasmspasm
 TreatmentTreatment

53. Obst. J
Anesthetic techniqueAnesthetic technique
Volatile AnestheticsVolatile Anesthetics
 Useful & well toleratedUseful & well tolerated
 Can be entirely eliminatedCan be entirely eliminated
 Disadv- CVS instabilityDisadv- CVS instability →→ vasodilationvasodilation →→ ↓↓perf.perf.
Press.Press. →→ ↓↓ blood velocityblood velocity →↑→↑ oxygen extractionoxygen extraction
→→ ↓↓ HBF & oxygen supplyHBF & oxygen supply
 Isoflurane—best maint. of HBF & oxygenIsoflurane—best maint. of HBF & oxygen
IPPV ?IPPV ?

54. Obst. 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 VTT & high airway& high airway
pressurespressures

55. Obst. J
Anesthetic techniqueAnesthetic technique
 Maintenance of BV and Renal functionMaintenance of BV and Renal function
 MannitolMannitol
 FrusemideFrusemide
 DopamineDopamine
 Adequate blood/component replacementAdequate blood/component replacement

56. Obst. J
MonitoringMonitoring
 BP,HR,SpO2BP,HR,SpO2
 EtCO2EtCO2
 CVPCVP
 Urine outputUrine output
 Core tempCore temp
 NMJ monitoringNMJ monitoring
 Blood lossBlood loss
BiochemicalBiochemical
B.Sugar,ABGB.Sugar,ABG
S.ElectrolytesS.Electrolytes
HematologicalHematological
Hb,PT,,PTTK,TEGHb,PT,,PTTK,TEG

57. Obst. J
Postoperative managementPostoperative management
All wellAll well  ExtubateExtubate
UnstableUnstable
-- Continue IPPV in Post.op. periodContinue IPPV in Post.op. period
-- 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

58. Obst. J
Thank YouThank You