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Overview (Groote Schuur Hospital Guidelines by Dr Dee Batty)

Anaesthesia Guidelines for Hepatobiliary Surgery

Thoracic Epidural Analgesia (TEA)

Indications

Major Open Liver Resection

• Complex minor resections involving:
  • Posterior or central liver positions.
  • Redo surgery.
  • Portal hypertension.
  • Inferior vena cava (IVC) involvement.
  • Biliary-enteric anastomosis.

Comorbidities:

• Chronic obstructive airway disease (COAD) or other conditions where TEA assists in intraoperative and/or postoperative management.

Preoperative Preparation

1. Baseline Monitoring and Access

   • Arterial line (A-line).
   • Central venous pressure (CVP) monitoring.
   • Large-bore vascular access.

2. Essential Equipment

   • Underbody warming device.
   • Urinary catheter.

3. Medications

   • Prophylactic antibiotics (repeated every 4 hours).

4. TEA Establishment

   • Working epidural established pre-incision using bupivacaine 0.25%.
   • Intraoperative boluses or continuous infusion to maintain a sensory block two dermatomes above the incision site.

Intraoperative Management

1. Fluid Management

   • Employ fluid restriction combined with epidural-induced splanchnic and peripheral vasodilation to lower CVP until liver resection is complete.

2. Complex Major Open Liver Resection (OLR): Additional Measures

   • Peripheral cardiac output monitoring (e.g., EV1000).
   • Cell saver (± filter for cancer cases).
   • Venovenous bypass (if indicated).
   • Sheath placement and use of a high-flow blood transfusion and warming device (e.g., Ranger).

Postoperative Management

1. Analgesia

   • Epidural infusion: Bupivacaine 0.1% with opioid infusion for 48–72 hours as per protocol.
   • Supplement analgesia only as needed in a stepwise approach:
     • Oral analgesia: Tramadol or Tapentadol on postoperative day (POD) 2 or 3 when transitioning to the ward.
     • Consider patient-controlled analgesia (PCA) with fentanyl or morphine if additional control is required.

2. Adjuvant Medications

   • Paracetamol and NSAIDs (if applicable), although typically avoided in major resections or complex minor resections.

Notes

1. The bupivacaine/morphine infusion allows morphine accumulation, providing an additional 12–24 hours of analgesia post-TEA removal.
2. Avoid paracetamol and NSAIDs in cases of major resections or complex minor resections to mitigate potential complications.

Thoracic Epidural Alternative (TEA Alternative)

Indications for TEA Alternative

• Minor liver resections (involving fewer than three segments).
• Minor open liver resections.
• Laparoscopic liver resections.
• Major or complex minor resections if TEA is not possible or feasible.

Preoperative Preparation

1. Baseline Monitoring and Access

   • Arterial line (A-line).
   • Good vascular access (CVP monitoring not required).

2. Essential Equipment

   • Underbody warming device.

3. Medications

   • Prophylactic antibiotics, repeated every 4 hours.

4. Hemodynamic Management

   • Fluid restriction combined with adjuvants to lower CVP appropriately until liver resection is completed.

Intraoperative Analgesic Approach

Laparoscopic Liver Resection

• Intrathecal Morphine (ITM): Administered at the start of the procedure.
• Intravenous Adjuvants:
  • IV lignocaine and IV dexmedetomidine, initiated prior to incision and continued into postoperative high care for up to 24 hours.
• Local Analgesia:
  • Local bupivacaine at port sites (*consider lignocaine dose in total dose calculation).

Conversion To Open Surgery

• IV Lignocaine: Discontinue 30 minutes before the end of the procedure.
• Wound Infusion Catheters (AWC): Placed at the end of surgery, administer:
  • 0.25% bupivacaine bolus at placement (*consider lignocaine dose in total dose calculation).
  • Continue bupivacaine infusion via AWC for up to 72 hours postoperatively.

Postoperative High Care Management

1. Oral Analgesics:

   • Initiate as needed in a stepwise manner.
     • Tramadol.
     • Paracetamol and NSAIDs as appropriate (avoid in major or complex minor resections).

2. Systemic Opioid Use:

   • Minimise systemic opiate use.
   • Reserve morphine boluses for rescue analgesia only.

3. Patient-Controlled Analgesia (PCA):

   • Day 0: Consider fentanyl PCA.
   • Day 1 (24 hours post-spinal morphine): Transition to fentanyl or morphine PCA (+/- ketamine if needed).

4. Additional Considerations:

   • Monitor for respiratory depression for 24 hours if ITM was used.
   • In resource-limited settings lacking high-care beds, omit ITM and use IV morphine at approximately 40% of expected dose (adjuvants reduce total opioid requirements).
   • If AWCs are unavailable:
     • Use epidural catheters as wound infusion catheters.
     • Insert one catheter into the posterior rectus sheath and one into the transversus abdominis plane (TAP). Attach to an electronic infusion pump for delivery.

Notes

1. Avoid paracetamol and NSAIDs in major and complex minor resections. In minor resections, avoid NSAIDs if contraindicated.
2. Consider all local anesthetic dosing (e.g., lignocaine and bupivacaine) when calculating maximum allowable dose to avoid toxicity.

Thoracic Epidural Analgesia (TEA)

Goals of TEA

• Preemptively establish a functioning epidural before incision.
• Maintain sensory block two dermatomes above incision level intraoperatively and postoperatively.
• Support splanchnic perfusion during the critical early period of liver regeneration (2–3 days postoperative).

Intraoperative Management

Fluid Management and Hemodynamic Goals

• Fluid restriction combined with epidural-induced splanchnic and peripheral vasodilation:
  • Lowers CVP and facilitates portocaval decompression until liver resection is complete.
• Target Hemodynamics:
  • MAP can safely decrease by up to 30% without compromising oxygen supply.
  • Ideal parameters:
    • MAP ~60 mmHg.
    • HR ~60 bpm.
  • Adjust targets based on patient-specific needs.

Pharmacologic Support for MAP

• Use IV phenylephrine for low MAP with high HR.
• Use IV ephedrine for low MAP with low HR.

Fluid Resuscitation Post-Hemostasis

• After achieving hemostasis:
  • Return to normovolemia.
  • Some centers initiate goal-directed fluid therapy (GDFT) with cardiac output monitoring at this point, continuing into the postoperative period.

Postoperative Management

Fluid Management

1. Baseline Maintenance:
   • Glucose-maintaining solution (GMS) at 1.2 ml/kg/hour.
2. Rehydration:
   • 1 L IV infusion over 24 hours.
3. Boluses as Required:
   • Use Voluven, Volulyte, or Balsol in 200 ml increments to maintain:
     • Urine output: 0.3–0.5 ml/kg/hour.
     • MAP > 60 mmHg.

Fluid Therapy Notes

• GDFT (goal-directed fluid therapy):
  • May optimize outcomes with stroke volume variation (SVV) and peripheral cardiac output monitoring.
  • However, evidence from studies is inconclusive, and this may not be widely available.
• Avoid restrictive fluid policies to support liver regeneration, which requires increased cardiac output.
• Most patients can tolerate oral free fluids starting at 4 hours postoperative, progressing to full ward diet as tolerated.

Epidural Management

Postoperative Analgesia Protocol

• Always combine bupivacaine with an opiate (morphine or fentanyl unless contraindicated):
  • Prevents tachyphylaxis and reduces escalating local anesthetic requirements.

Monitoring And Maintenance

1. Sensory Level:
   • Maintain level two dermatomes above incision using infusion and top-up boluses as needed.
   • Adjust infusion rate early based on hourly checks for the first 3–4 hours, then every 4 hours.
2. Motor Function:
   • Monitor hourly for return of motor power initially, then every 4 hours once motor power has returned.

Safety Considerations

• Vigilantly monitor for epidural hematoma per established protocol.

TEA (Thoracic Epidural Analgesia) – How to Make It Work

Source: GSH and UCTPAH (2021)

Aims

1. Provide an effective anaesthetic for a well-informed and cooperative patient.
2. Establish the epidural block prior to incision and maintain a level two dermatomes above the incision (e.g., T4 for upper abdominal surgery).
3. Transition seamlessly into the postoperative phase with a continuous infusion of 0.1% bupivacaine plus an opioid for:
   • Maximal pain relief.
   • Neural deafferentation.
   • Minimal side effects.
4. Avoid intravenous opioids except during the transition from epidural to IV morphine infusion or PCA.
5. Educate patients about risks without causing undue anxiety, emphasizing protocols to detect and manage complications.

Technique

Patient Positioning

• Positioning contributes 90% to the success of the epidural.
• Use anxiolysis with midazolam titrated to achieve a cooperative patient.

Epidural Level

• Ideal level: T9–T10 for upper abdominal surgery (advantage of horizontal needle insertion).
• Avoid higher levels (e.g., T7–T8) unless required; higher insertion does not significantly improve the block and may cause urinary catheter discomfort.

Sterile Preparation

• Use chlorhexidine with alcohol and allow it to dry.
• Full sterile precautions: Mask, gloves, cap, gown.

Epidural Catheter Placement

• Use loss of resistance (LOR) with saline.
• Insert multi-orifice catheter 5–7 cm into the epidural space (do not advance further to minimize vessel infiltration risk).
• Test dose: 2 ml of 2% lignocaine to confirm proper placement.

Intraoperative Management

Block Establishment

1. Preemptive Blockade:

   • Use a bupivacaine-lignocaine mix (e.g., 7 ml of 0.5% bupivacaine + 3 ml of lignocaine).
   • Sensory level (T4) achieved within 3–4 minutes.
   • Volume required: 12–20 ml total for a T4 block (to cover ~2–6 dermatomes above the incision level).

2. “Paint the Fence” Technique:

   • Administer half the total calculated volume 30 minutes before incision to increase block density.
   • _Skip this step if cardiovascular instability exists or time is constrained; instead, give the first hourly volume 1 hour post-insertion.

3. Maintenance:

   • Administer 4/5 of the original volume hourly:
     • Bolus or infusion with 0.25% bupivacaine intraoperatively.
   • Start infusion immediately after the first bolus (at 1 hour).
   • Do not stop boluses or infusion intraoperatively. Support blood pressure with:
     • IV fluid boluses.
     • Ephedrine or low-dose phenylephrine if required.

4. Local Anaesthetic Around Drains:

   • Apply local anaesthetic to drain sites before the procedure concludes.

Postoperative Management

Infusion

• Continue the intraoperative infusion rate using 0.1% bupivacaine plus an opioid of choice (e.g., morphine or fentanyl).

Monitoring

• First 2–3 hours: Check sensory level hourly to ensure a steady state. Adjust the infusion rate early if required.
• Top-ups:
  • Use 0.25%–0.5% bupivacaine to increase block density or raise the sensory level.
  • Bolus 3–5 ml every 5 minutes as needed, up to the total original dose.
  • Wait too long between boluses, and block density increases without raising the sensory level.

Blood Pressure Support

• Blood pressure instability is uncommon (if the patient is not fluid-deficient) after 3–4 hours of a well-established block.
• Use IV fluid boluses or ephedrine if required to support blood pressure.

Local Anaesthetic Use

• Mechanism: Blocks afferent and efferent signals, suppressing the surgical stress response. Facilitates:
  • Return of gastric motility.
  • Reduction in inflammation.
  • Decreased blood viscosity.
• Dosing:
  • Postoperative infusion rates up to 25 ml/hour of 0.1% bupivacaine are acceptable, provided total bupivacaine dose does not exceed 2 mg/kg/4 hours.
• Agent Selection:
  • Bupivacaine, levobupivacaine, ropivacaine are all effective.
  • Clinical advantages (e.g., less cardiotoxicity, reduced motor block) of levobupivacaine and ropivacaine are minimal at the low doses used.

Opioids In TEA

• Mechanism: Act synergistically with local anaesthetics, reducing the required concentration of LA.
• Selection and Effects:
  1. Morphine (hydrophilic):
     • Slower onset (30–60 minutes).
     • Extensive CSF spread, leading to delayed respiratory depression.
     • Long duration (6–24 hours).
  2. Fentanyl/Sufentanil (lipophilic):
     • Rapid onset (5–10 minutes).
     • Limited CSF spread and shorter duration (2–4 hours).
     • Most of the drug exerts systemic effects rather than spinal action due to low bioavailability at the dorsal horn.

Postoperative Infusion Example

• Morphine Infusion:
  • Concentration: 0.05 mg/ml morphine + 0.1% bupivacaine (10 mg morphine + 200 ml 0.1% bupivacaine).
  • Dose: 6–15 ml/hour (300–750 µg/hour morphine).
  • Start intraoperatively or immediately postoperatively.

Advantages of Morphine Infusion

• Accumulated CSF morphine provides up to 24 hours of analgesia after stopping the infusion, easing transition to oral analgesics.
• Reduced total dose minimizes side effects (e.g., respiratory depression, nausea, pruritus).

TEA Alternative Strategy

Aim

To replicate the following benefits of thoracic epidural analgesia (TEA):

• Analgesia: Via ITM (intrathecal morphine), dexmedetomidine (DEX), and lignocaine.
• CVP Lowering: Through DEX and fluid restriction.
• Stress Reduction: By minimizing hemodynamic disturbances.
• Immunomodulation: Utilizing DEX and lignocaine.

Technique

Monitoring and Access

• Nasogastric Tube (NGT): Not required.
• Arterial Line (A-line): Routine for continuous hemodynamic monitoring.
• Central Venous Pressure (CVP):
  • Required for:
    • Hepatectomy, extended hepatectomy, or complex segmentectomy.
    • Central liver resections, proximity to major vessels, redo surgeries.
    • Cases with portal hypertension, biliary-enteric anastomosis, or sepsis risk.
  • Not required for:
    • Laparoscopic resections.
    • Simple minor liver resections.
  • Alternatives: Use stroke volume variation (SVV) as a surrogate for CVP. Requires a peripheral cardiac output monitor attached to the A-line. Useful for goal-directed fluid therapy (GDFT) in major or complex open liver resections (OLR) if available.

Fluid Management

• Restrict fluids to maintain low CVP until liver resection and hemostasis are complete.

Anaesthesia Plan

IV Access

• Large Bore IV Access: 14G–16G.
• Second Peripheral Line: For drug infusions (DEX, lignocaine, phenylephrine).

Intrathecal Morphine (ITM)

• Dose: 150–250 µg, diluted to 1.5–2 ml with saline.
• Optional Addition:
  • Plain bupivacaine (3–4 ml): If stable hemodynamics and surgery duration >3–4 hours are expected.
  • Adequate volume required to provide coverage for the upper abdominal incision.
  • Slow onset contributes to hemodynamic stability.
• Note: ITM provides 12–24 hours of postoperative analgesia but is not sufficient for intraoperative surgical analgesia.

Dexmedetomidine (DEX)

• Concentration: 4 µg/ml.
• Infusion Rate: 0.1–0.5 µg/kg/hour, titrated to effect (target HR ~60 bpm, MAP ~60 mmHg).
• Optional Bolus: Up to 0.5 µg/kg at initiation.
• Avoid:
  • Large boluses (e.g., 1 µg/kg) due to risk of hypertension and bradycardia via α2B receptor activation.

IV Lignocaine

• Loading Dose: 1.5 mg/kg over 10 minutes.
• Infusion Rate: 1 mg/kg/hour.
• Duration: Continue until 30 minutes prior to the end of surgery.

Intraoperative Opioids

• Fentanyl: 200–400 µg during the procedure.
• Morphine: Optional early administration (approximately 40% of the usual anticipated dose).
• Note: IV DEX and lignocaine reduce intraoperative opioid requirements by up to 50%.

Postoperative Analgesia

Analgesic Benefits

• ITM provides significant postoperative pain relief for 12–24 hours.
• Respiratory depression risk with ITM: 0.3–3%.

Respiratory Considerations

• Increased risk of respiratory depression when combining:
  • Spinal morphine.
  • Parenteral opioids.
  • Sedatives (e.g., dexmedetomidine).

Wound Infusion Catheters

• Single catheter:
  • Use 0.2% bupivacaine.
• Double catheter for midline incisions:
  • Administer 0.2% bupivacaine at 5 ml/hour per catheter (or 8 ml/hour total via a splitter).

Dexmedetomidine

• Continue infusion in high care: 0.1–0.3 µg/kg/hour.

Stepwise Supplementation

• Oral analgesics:
  • Tramadol or Tapentadol.
• As appropriate:
  • Paracetamol (IV or oral).
  • NSAIDs (IV or oral), only if indicated and appropriate for patient condition.
• For breakthrough pain:
  • Morphine boluses as needed.
  • Fentanyl PCA can be used but is usually deferred until Day 1 during transition to the ward.

Respiratory Monitoring

Monitoring Schedule

• First 12 hours: Hourly assessment of respiratory rate and level of consciousness.
• Next 12 hours: Every two hours.
• Additional Monitoring:
  • Continuous pulse oximetry.
  • ABG analysis for CO₂ monitoring, if indicated.

Risk Factors for Respiratory Depression

Pharmacological Factors

• Higher intrathecal morphine doses.
• Systemic opiate co-administration.
• Co-administration of sedatives or magnesium.

Patient-Specific Factors

• Advanced age, female sex.
• Conditions: OSA, COPD, obesity, diabetes mellitus, cardiac/neurological/renal disease, opioid dependence.

Treatment for Respiratory Depression

• Administer low-dose naloxone infusion for up to 12 hours if required.

Fluid Management

Maintenance Fluids

• GMS IVI: 1.2 ml/kg/hour.
• Rehydration: 1 liter IVI over 24 hours.

Volume Boluses (as needed)

• Use Voluven, Volulyte, or Balsol in 200 ml increments to maintain:
  • Urine output: 0.3–0.5 ml/kg/hour.
  • MAP > 60 mmHg.

Fluid Strategy Based on Resection Type

• Major Resections: Follow the TEA guideline approach (avoid restrictive fluid policies).
• Minor Resections: Maintain normovolemia with minimal reliance on volume boluses

Use Of NSAIDs and Paracetamol

Recommendations

• Both are supported by ERAS and Prospect guidelines for liver resection analgesia.
• Their use depends on:
  • Extent of liver resection.
  • Liver condition (e.g., cirrhosis, fatty liver, recent chemotherapy, ischemic insult).
  • Comorbidities.

Contraindications for NSAIDs

• Absolute:
  • Elderly patients, peptic ulcer disease, gastritis.
  • Hypertension, cardiovascular disease, renal insufficiency.
• Cox-2 Inhibitors:
  • Contraindicated in ischemic heart disease (IHD), stroke, and renal impairment.
• Relative (Use with caution):
  • Hypertension, hyperlipidemia, diabetes, peripheral artery disease.
  • Smokers, patients at risk for AKI, or those with stress ulceration.

Administration

• Use the lowest effective dose for the shortest duration (<5 days perioperatively).

Links

Pancreatoduodenectomy (Whipple’s procedure)

Liver transplant

Liver resection

ICU and liver disease

Neuraxial and Epidural

References

1. Batty, D. (2021). Guidelines for Anaesthesia for Hepatobiliary Surgery: GSH and UCTPAH. Unpublished institutional guidelines, Groote Schuur Hospital and University of Cape Town Private Academic Hospital.

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