Perioperative management of a patient with Gilberts syndrome and rheumatic heart disease

Abstract

Anaesthetic management of patients with hepatic dysfunction can be quite challenging, as many anaesthetic agents are metabolized by liver. Heart disease on anti coagulation can pose additional challenge. Here we report a case of Gilbert's syndrome with rheumatic heart disease on anti coagulation posted for elective hernia repair.

Anesthetic management of a case of Gilbert's syndrome for mitral and aortic valve replacement: Role of transesophageal echocardiography

“…Previous case reports on GS undergoing noncardiac surgeries have documented better outcome. [ 3 6 ] However, there is limited literature on the use of TEE for monitoring hepatic perfusion in GS patients undergoing cardiac surgery. GS is characterized by unconjugated hyperbilirubinemia with the absence of hemolysis or underlying liver disease.…”

“…[ 1 2 ] It occurs due to an abnormal conjugation of bilirubin caused by deficiency of bilirubin uridine diphosphate glucuronyl transferase enzyme. [ 3 ] Majority of GS patients present with mild jaundice (<6 mg/dl) but when exposed to triggering factors such as stress, infection, fasting, and exercise will result in exacerbation of the disease process. [ 4 ] General anesthesia (GA), cardiac surgery and cardiopulmonary bypass (CPB) can act as precipitating factors which may worsen the already compromised hepatic function.…”

The use of TIVA in a patient with Gilbert's syndrome

“…Perioperative goals are to minimise fasting and stress during the perioperative period while avoiding hepatotoxic drugs and those which are exclusively metabolised by the liver. It is important to maintain hepatic blood flow by keeping the mean arterial pressure greater than 60 mmHg [5]. Plasma bilirubin concentrations seldom exceed 5 mg.dl -1 but will increase two to threefold with fasting, illness or stress.…”

“…Stressors that may aggravate the symptoms of Gilbert's syndrome include prolonged fasting, surgery, infection, exercise, fatigue, alcohol intake and menstruation [6]. If general anaesthesia is required, it is recommended that short-acting agents or those with extra hepatic metabolism are used [5]. Among inhalational agents, halothane should be avoided as it has the potential to cause postoperative jaundice.…”

Perioperative management and anaesthetic considerations for adult patients with Gilbert’s syndrome and oral cancer: review and case report

“…All inhaled anaesthetics decrease the total liver blood flow and this decrease is maximum with halothane and minimum with isoflurane [24,25]. The hepatic metabolism is highest with halothane (15-40% of drug), followed by enflurane (2.4%), sevoflurane (2-5%), isoflurane (<0.2%) and desflurane (0.02%) [8,26].…”