Obstructive jaundice

Structure: patient factors (sepsis/aspiration/coagulation/renal), procedure factors (positioning, access), and a pragmatic plan (sedation vs GA).

• Concerns
  • Cholangitis → vasoplegia at induction, need for vasopressors, potential ICU
  • Aspiration risk: delayed gastric emptying, opioids, gastric outlet obstruction, prone/semi-prone limits airway access
  • Coagulopathy from vitamin K deficiency, thrombocytopenia in sepsis/malignancy
  • Renal vulnerability, avoid hypotension and nephrotoxins
• Plan
  • If septic/aspiration risk/complex ERCP: RSI, cuffed ETT, controlled ventilation, arterial line if unstable
  • If low risk/short ERCP: deep sedation may be acceptable with capnography, suction, readiness to convert to GA
  • Antibiotics as indicated, fluids and vasopressors prepared, post-procedure monitoring for pancreatitis/sepsis

Aim: link cholestasis to vitamin K malabsorption and reduced synthesis of vitamin K-dependent clotting factors, then give a practical correction strategy.

• Mechanism
  • Bile salts are required for micelle formation and absorption of fat-soluble vitamins (A, D, E, K)
  • Vitamin K deficiency → reduced γ-carboxylation → ↓ activity of factors II, VII, IX, X (and proteins C/S) → prolonged PT/INR
• Management
  • Give IV vitamin K (time-dependent effect, best if elective)
  • If urgent surgery or active bleeding: PCC or FFP guided by INR/TEG/ROTEM, correct fibrinogen/platelets as needed
  • Neuraxial techniques only if coagulation acceptable and stable, document trend and timing of correction

Think vasoplegia (sepsis/endotoxin), hypovolaemia, myocardial depression, bleeding, anaphylaxis, and drug effects, treat simultaneously.

• Likely causes
  • Septic vasodilation/endotoxaemia, exaggerated response to induction agents
  • Relative hypovolaemia from poor intake, third spacing, diuretics
  • Myocardial depression (sepsis/ischaemia) or arrhythmia, less commonly anaphylaxis
• Immediate management
  • 100% O2, check airway/ventilation, deepen/adjust anaesthesia, confirm rhythm, treat arrhythmias
  • Give vasopressor boluses (e.g., metaraminol/phenylephrine) and start noradrenaline infusion early if persistent
  • Fluid bolus guided by response, consider arterial line, ABG/lactate, search for bleeding/anaphylaxis

FRCA focus: mechanisms + practical anaesthetic measures.

• Why AKI risk is increased
  • Systemic inflammation/endotoxaemia → renal vasoconstriction and microcirculatory dysfunction
  • Hypovolaemia and vasodilation → reduced renal perfusion pressure
  • Higher susceptibility to nephrotoxins and contrast, sepsis-associated tubular injury
• Risk reduction
  • Maintain MAP (individualised, often ≥65 mmHg, higher if chronic HTN) with fluids + vasopressors
  • Avoid NSAIDs in high-risk patients, dose-adjust renally cleared drugs, careful with contrast
  • Monitor urine output, creatinine trend, lactate/acid-base, consider goal-directed fluid therapy in major surgery

Often overlooked: functional status, skin integrity, drug binding, and peri-operative delirium risk.

• Pruritus
  • Fatigue and reduced physiological reserve, consider delirium risk in older/septic patients
  • Skin damage may affect monitoring/IV access, infection risk if excoriated
• Malnutrition/hypoalbuminaemia
  • Reduced protein binding → increased free fraction of some drugs, titrate opioids/sedatives carefully
  • Impaired immunity and wound healing, higher postoperative complication risk

Major upper abdominal surgery: long duration, large fluid shifts, bleeding risk, and high postoperative morbidity.

• Pre-op
  • Assess for cholangitis, correct INR with vitamin K, crossmatch, evaluate cardiopulmonary reserve and frailty
  • Discuss postoperative critical care, analgesia strategy, and transfusion plan
• Intra-op
  • A-line, large-bore IVs, consider CVC, active warming, serial ABGs, urine output monitoring
  • Goal-directed fluids, early noradrenaline for vasoplegia, blood products guided by labs/viscoelastic testing
  • Analgesia: epidural if coagulation acceptable and haemodynamics allow, otherwise intrathecal opioid/regional blocks + multimodal
• Post-op
  • Monitor for bleeding, sepsis, AKI, respiratory complications, manage glycaemia and nutrition early

Common FRCA theme: recognise and escalate early.

• Post-ERCP pancreatitis
  • Epigastric pain, vomiting, raised amylase/lipase, can progress to SIRS/organ failure
  • Management: fluids, analgesia, antiemetics, oxygen, critical care if severe
• Bleeding
  • Haematemesis/melaena, hypotension, drop in Hb, higher risk with coagulopathy/anticoagulants
  • Management: resuscitation, correct coagulopathy, endoscopic haemostasis ± IR/surgery
• Perforation
  • Severe pain, tachycardia, surgical emphysema, sepsis, imaging confirms
  • Management: antibiotics, NBM, surgical/IR input, may require laparotomy
• Cholangitis/bacteraemia
  • Fever, rigors, hypotension, treat as sepsis with antibiotics and ensure adequate drainage

Answer should mention: titration, protein binding, hepatic clearance, and context (sepsis vs stable).

• General approach
  • Use lower initial doses if vasodilated/septic, incremental dosing with close haemodynamic monitoring
  • Be cautious with highly protein-bound drugs if hypoalbuminaemic (greater free fraction)
• Opioids and sedatives
  • Prefer short-acting, titratable agents, avoid excessive long-acting sedatives, consider delirium risk
• Neuromuscular blockers
  • Use quantitative monitoring, choose agents with predictable clearance where possible, ensure full reversal

Key issues: coagulopathy and haemodynamic instability, provide realistic alternatives.

• Avoid/consider contraindications
  • Raised INR/low platelets or uncertain correction, ongoing sepsis, anticipated profound vasodilation/vasopressor dependence
  • Patient refusal, spinal pathology, or inability to safely manage epidural post-op
• Alternatives
  • Intrathecal morphine (if coagulation acceptable) + multimodal analgesia
  • Subcostal TAP/rectus sheath blocks, wound catheters, systemic adjuncts (ketamine, lidocaine per policy)

A high-yield answer is system-based: CVS, renal, coagulation, infection, CNS, pharmacology.

• Cardiovascular
  • Endotoxaemia/inflammation → vasodilation, increased sensitivity to anaesthetic-induced hypotension
• Renal
  • Hypoperfusion + inflammatory injury, increased risk with sepsis and nephrotoxins
• Haematology/coagulation
  • Vitamin K deficiency → prolonged PT/INR, thrombocytopenia possible
• Infection
  • Ascending infection, ERCP/surgery can precipitate sepsis
• Pharmacology
  • Altered hepatic excretion/uptake, increased free drug fraction, prolonged effects—titrate and monitor
• CNS/metabolic
  • Delirium risk, fat-soluble vitamin deficiency, impaired wound healing

Use a structured pre-op approach: identify cause/urgency, detect sepsis and organ dysfunction, correct reversible problems, plan level of care.

• Assess severity and urgency
  • Look for fever, hypotension, confusion, review imaging for level of obstruction and need for drainage
• Investigations
  • Crossmatch, consider ABG/lactate if septic, ECG ± echo/CPET if major surgery and time allows
• Optimisation
  • Treat sepsis, IV fluids, early vasopressors if required, consider ICU
  • Correct INR with vitamin K, manage anticoagulants, plan blood products if urgent
  • Address renal risk: avoid nephrotoxins, maintain perfusion, correct electrolytes, nutrition support
• Planning
  • Discuss epidural vs alternatives based on coagulation and haemodynamics, plan invasive monitoring and HDU/ICU bed

This is essentially anaesthesia for sepsis + source control, with added coagulopathy/AKI/aspiration considerations.

• Before theatre
  • Oxygen, cultures, antibiotics, fluids, lactate, start noradrenaline early if shock persists
  • Correct coagulopathy where possible, ensure blood availability
• Induction
  • A-line before induction if unstable, cautious dosing, vasopressor boluses and infusion ready
• Intra-op
  • Maintain MAP with noradrenaline ± inotrope if myocardial depression, careful fluid strategy
  • Monitor urine output, ABG/lactate, temperature control, glycaemic control
• Post-op
  • Ventilation/vasopressors may be required, ongoing antibiotics and organ support, monitor for DIC/AKI