CASE REPORT – RIGHT CASE REPORT – RIGHT HEPATECTOMYHEPATECTOMY

Dr.M.MuthuShenbagam,MD(Anes),DA.Dr.M.MuthuShenbagam,MD(Anes),DA.Asst.ProfessorAsst.Professor

Dept.of Anaesthesia,Dept.of Anaesthesia,Kanyakumari Govt.Medical College Kanyakumari Govt.Medical College

Hospital.Hospital.

•51yrs old Mr. Stephen from 51yrs old Mr. Stephen from Nagercoil,admitted at KGMCH Nagercoil,admitted at KGMCH with C/o. Abdominal pain > 6 with C/o. Abdominal pain > 6 months.months.Diagnosed by CT as Giant Diagnosed by CT as Giant Hemangioma (Rt) lobe of liver. Hemangioma (Rt) lobe of liver.

INVESTIGATIONSINVESTIGATIONS

Hb Hb - 10 gms %- 10 gms %

LFTLFT- WNL- WNL

Coagulation profileCoagulation profile - WNL - WNL

• Planned for Rt Hepatectomy.

• Assessed

• Procedure & risk explained to the patients and relatives.

• Adequate blood reserved.

•Patient was shifted to OT.Patient was shifted to OT.

Started IV linesStarted IV lines 2 widebore 16G venflon – 2 widebore 16G venflon –

Rt&Lt arm.Rt&Lt arm. One 18G venflon in LL. One 18G venflon in LL.

•Monitors.Monitors.- Pulse oximeter- Pulse oximeter- NIBP - NIBP - ECG- ECG- CVP- CVP-Urine output-Urine output

ANAESTHESIA PLAN ANAESTHESIA PLAN

ETGA + Thoracic Epidural ETGA + Thoracic Epidural AnesthesiaAnesthesia

Emergency drugs ,NTG, Emergency drugs ,NTG, Dopamine infusion kept ready.Dopamine infusion kept ready.Premed :Premed :

-Inj.Glycopyrolate 0.2mg IV -Inj.Glycopyrolate 0.2mg IV - Midazolam 2mg IV- Midazolam 2mg IV- Pethidine 50mg IV- Pethidine 50mg IV

Under Asepsis Rt Internal Under Asepsis Rt Internal jugular vein cannulated &jugular vein cannulated &Triple lumen CVP catheter Triple lumen CVP catheter inserted under seldinger inserted under seldinger technique & distal port used for technique & distal port used for CVP measurement.CVP measurement.

Under asepsis, RT lat-position, Under asepsis, RT lat-position, 18G Epidural Catheter inserted 18G Epidural Catheter inserted in T10-T11space& 5cm kept in T10-T11space& 5cm kept inside& 10ml of 0.2% inside& 10ml of 0.2% Ropivacaine + 25mcg Fentanyl Ropivacaine + 25mcg Fentanyl given through Epidural Catheter given through Epidural Catheter

INDUCTION : Thiopentone 250mgINDUCTION : Thiopentone 250mg IV IV Scoline 75mg IV Scoline 75mg IV

INTUBATION INTUBATION : 8.0 ID Endo tracheal : 8.0 ID Endo tracheal tube & BAE checked tube & BAE checked

MAINTENANCE MAINTENANCE – N – N22O/OO/O22

- Fentanyl - Fentanyl - Atracurium - AtracuriumLA supplementation thro LA supplementation thro Epidural.Epidural.

Fluid- Maintenance with Fluid- Maintenance with Crystalloids& Colloids.Crystalloids& Colloids.

CVP was kept in the range of CVP was kept in the range of 4-6 cm water.4-6 cm water.

NTG infusion was used to NTG infusion was used to minimize blood loss.minimize blood loss.

Vascular control was done with Vascular control was done with inflow clamping of Hepatic A / inflow clamping of Hepatic A / portal veinportal vein (Pringle maneuver)(Pringle maneuver)

Intra operatively, during resection Intra operatively, during resection phase, huge blood loss from middle phase, huge blood loss from middle hepatic veins.hepatic veins.

BP to 60/40mmHgBP to 60/40mmHg

MANAGEMENT:MANAGEMENT: - Mephentermine 12 mg Bolus - Mephentermine 12 mg Bolus - Colloids/Blood 2 units rushed - Colloids/Blood 2 units rushed - Dopamine drip - which was - Dopamine drip - which was stopped after control stopped after control

BP to 100/70mmHgBP to 100/70mmHg

•Rest of the intraop period- uneventfulRest of the intraop period- uneventful

Surgery lasted for 6 hrs.Surgery lasted for 6 hrs.

Blood loss – app. 2 to 3 lit.Blood loss – app. 2 to 3 lit.

Intraoperativly 6 units of blood Intraoperativly 6 units of blood transfused & calcium supplement transfused & calcium supplement given.given.

At the end of procedure – At the end of procedure – reversal with Neostigmine + reversal with Neostigmine + Glycopyrolate Glycopyrolate

Extubated awake.Extubated awake.

Postop period – Vitals – StablePostop period – Vitals – Stable

Shifted to ISCUShifted to ISCU..

Problems in Liver ResectionProblems in Liver Resection

Long operation time Long operation time Fluid Shifts Fluid Shifts Sudden unexpected blood Sudden unexpected blood lossloss CoagulopathyCoagulopathy HypothermiaHypothermia

Low CVP Technique – controversial

Aids surgery Minimise blood loss

But, increased risk of Airembolism Potential for Hemodynamic instability if

bleeding is sudden & significant

THANK YOUTHANK YOU