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Surgery Essay

Outline briefly the physiological implications in


preparing a severely jaundiced patient for surgery.

Jaundiced patients usually have impaired clotting. This is


largely a failure to absorb vitamin K form the gut. This is
manifested as a prolonged coagulation time. It can be reversed
by an intramuscular administration of vitamin K pre-
operatively. Other clotting problems may be present and hence
a coagulation profile should be done, and clotting factors such
as fresh frozen plasma should be arranged as necessary.

Jaundiced patients have a higher risk of developing renal


failure than other patients undergoing a similar degree
surgery for other causes. The precise mechanism for this is not
well understood. The absorption of an endotoxin from the
intestine, which is usually removed by the reticuloendothelial
system of the liver, may be one reason. Additionally, there may
e a yet unidentified factor produced by the liver itself which
helps modulate renal function. To overcome this risk jaundiced
patients should be fully hydrated preoperatively. This means
setting up an IV infusion the day before. Also, osmotic dieresis
such as mannitol may be given during and post operatively, as
well as dopamine. This should be given at 2.5μg/l/min via a
central line to maximise renal function. Central venous
pressure should be monitored via a CVP line and a catheter
inserted to monitor renal output, which is to be kept above
40ml/h.

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Surgery Essay

Patients with obstructive jaundice, especially if due to


malignancy, are very malnourished. These patients may need
pre- and post-operative nutrition. However, there is no
evidence that pre-operative nutrition is of advantage to these
patients. However, malnutrition will lead to poor wound healing
and increased risk of infections. The patient should hence be
covered with broad spectrum antibodies, preferably those that
appear in the bile. This will also prevent the most feared
complications in patients with obstructive jaundice:
cholangitis.

10/02/09