managment of full term preg.with hepatic encephalopathy

Started by amarkatira, April 28, 2007, 04:27:10 PM

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amarkatira

managment of full term preg.with hepatic encephalopathy???

frontier

hi,
  choose GA .induction with thiopentone & intubation with succinylcholine & vecuronium as muscle relaxant for maintenance with nitrous oxide & oxygen.isoflurane  or sevoflurane or desflurane as inhalation agent.least use of opioids.nasogastric tube to be passed.no use of sedatives.with regards.

jafo1964

Thio is OK

No suxa  - cholinesterases are produced by liver which in this case is diseased

Non difficult airway - Atracurium or cis atra , No Vec  because it has hepatic metabolism and hence prolonged action

Difficult airway - Between Suxa with risk or Rocuronium

Narcotics - Fentanyl

Needs RSI

Watch for hypoglycaemia, Coagulopathy, Hepatorenal syndrome, Hypothermia

Mannitol 0.25 mg / kg

Post - op ventilation on standby

Epidural for post -op analgesia - guarded - coagulopathy




frontier

hi jafo sir,
    i am in favour of succinylcholine as in such cases one should go for rapid sequence intubation with preoxgenation & cricoid pressure with use of sux or another option is awake intubation.the reduced level of pseudocholineesterase is hardly of any clinical significance.now as far as the use of vecuronium is concerned  cisatracurium is drug of choice which is not available in our part.so now the choice is between atracurium & vecuronium.even if we use vecuronium which is biliary excretion dependent if the dose is less than .15 mg/kg body weight the action of vecuronium is not going to be prolonged as per the studies.so vecuronium can also be used in minimal doses .yes post op ventilation important other factors like electrolye imbalance,hypoglycemia,hypotherma,GI bleeding very important.with regards.

jafo1964

Totally agreed with you frontie

There is a concept called MODIFIED RSI
if you can adequately mask ventilate
induce  give NDP relaxant like vec / atra . ventilate for 3 mins and intubate
Accepted technique provided you can ventilate and maintain cricoid pressure for 3 mins

RATIONALE
ASA guidelines for failed intubation in obstetric GA
If failed intubation, check mask ventilation. If possible then proceed to add N2O + inhalational . Continue anaes with mask ventilation and cricoid pressure and proceed with surgery
So the key is not quick intubation but airway protection and adequate ventilation

Between Atra and Vec not much difference but remember that Atra can undergo Hoffman degradation and VEc is totally hepatic dependant
Also vec has active metabolite 6 desacetyl vec with 25% activity of parent compound. Atra has no active metabolites
So why not just use the theorotically safe option

To tell you the truth at a govt hospital for renal transplant recepient I have used Pancuronium and Pentazocaine because nothing else was available. We even extubated the patient. But that does not make it the right thing to do and if you get into trouble with MLC it will be easier to defend the theorotically right drug over the wrong one