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

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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

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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

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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

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Hepatic Blood SupplyHepatic Blood Supply

Unique ?Unique ?

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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 ?

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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