hepatits and hepatitis b and hepatits c universal precations.pptx

Anaesthesia consideration of hep b and c

1. HEPATITIS – ACUTE AND CHRONIC, DEFINATION, TREATMENT ,UNIVERSAL SAFETY PRECAUTIONS TAKEN ON PATIENTS WITH HEPATITIS B AND C –ANAESTHETIC CONSIDERATION OH HBSAG AND HCV POSTIVE PATIENT What Is Hepatitis? Hepatitis means inflammation of the liver  Hepat (liver) + itis (inflammation)= Hepatitis Hepatitis is defined as inflammation of the liver that can result from a variety of causes, such as viral infection, heavy alcohol use, autoimmune disorders, drugs, or toxins .  Viral hepatitis means there is a specific virus that is causing your liver to inflame (swell or become larger than normal) MODERATOR: DR NARENDRA K. DENWAL PRESENTER : DR VARDAAN BHARDWAJ

2. hepatitis is classified as acute or chronic based on the duration of the inflammation and insult to the hepatic parenchyma. If the period of inflammation or hepatocellular injury lasts for less than six months, characterized by normalization of the liver function tests, it is called acute hepatitis . I f the inflammation or hepatocellular injury persists beyond six months, it is termed chronic hepatitis. Acute hepatitis is a term used to describe a wide variety of conditions characterized by acute inflammation of the hepatic parenchyma or injury to hepatocytes resulting in elevated liver functions

3. Infectious causes : Hepatotropic viruses : Hepatitis A Virus(HAV) Hepatitis B Virus (HBV) Hepatitis C Virus (HCV) Hepatitis D Virus (HDV) Hepatitis E Virus (HEV) Nonhepatotropic virus : Epstein-Barr virus (EBV) Cytomegalovirus (CMV) Herpes simplex virus (HSV) Coxsackievirus Adenovirus Dengue virus Bacteria, fungi, and parasites Alcohol-related : fatty liver disease, acute alcoholic hepatitis, or alcoholic cirrhosis

4. Drugs and toxins Dose-dependent, e.g. acetaminophen (paracetamol) Non-dose-dependent, e.g antibiotics and anticonvulsants but also statins, NSAIDs, herbal/nutritional supplements Other toxins, e.g., mushroom ( Amanita phalloides) and dietary supplements, carbon tetrachloride  Immunologic or inflammatory conditions Autoimmune hepatitis Biliary disease such as primary biliary cholangitis or primary sclerosing cholangitis. Metabolic or hereditary Nonalcoholic fatty liver disease Hemochromatosis Wilson's disease

5. Clients who have any form of viral  hepatits  will benefit from: Resting. Avoiding alcohol and discontinuing drug use. Avoiding other substances that can harm the liver, including  acetaminophen  (Tylenol) in large doses. Eating nutritious, well-balanced meals. Getting vaccinated against hepatitis A and  hepatits B. MANAGEMENT

6. Treatment for Hepatitis A Because  hepatitis A  is always acute, its treatment is generally limited to addressing symptoms, monitoring liver health, and letting the  virus  run its course. recently exposed to hepatitis A virus (HAV) might be advised by their medical care providers to receive the HAV vaccination or  immunoglobulin  injection to reduce the likelihood of becoming ill. In rare cases,  hepatitis A  leads to severe liver problems that require medication, hospitalization, or transplantation.

7. Drugs-drugs cannot cure hepatitis-B. But they do reduce the damage caused by the virus. (Pegylated inter feron . It reduce replication of virus) Nucleotide analogues Hepatitis B Antiviral therapy. Test regular. Avoid Jung food, alcohol and NSID Rest of liver TREATMENT MANAGEMENT

8. HEP C Antiviral treatment helps the body fight off HCV  infection   When the virus is not detected in the blood of a patient who is receiving antiviral treatment, and when it remains undetected for 6 months after treatment is completed, the patient is said to have an  S ustain virologic response The virus does not return in 95 percent to 99 percent of patients who achieve an SVR, and it does not appear to cause further damage However, an  SVR  does not make a person immune to reinfection. If reexposed to HCV, a person could be reinfected. The standard recommended treatment for  hepatitis C  is a combination of pegylated  interferon  injections and  ribavirin FDA approved two new oral medications,  boceprevir  and  telaprevir .

9. Anaesthetic consideration for Chronic Hepatitis Elective surgery has been reported to be safe in asymptomatic patient with mild-moderate chronic hepatitis. Symptomatic and histological severe CH have increased surgical risk particularly if hepatic synthetic or excretory function is impaired

10. Chronic alcoholic patient should be abstinent from alcohol for atleast 6 months to undergo elective procedure. NASH not a contraindication for elective surgery (>30% hepatocytes if contain fat - increased mortality) Hemochromatosis - Evaluate for complication such as diabetes, hypothyrodism and cardiomyopathy. Wilsons disease - Antipsychiatric medication has to be continued(surgery can ppt or aggravate neurological symptoms)

11. Body fluids to be treated under Universal Precautions Blood. Blood-stained body fluids. Semen. Vaginal secretions. Tissues. CSF, Amniotic, Pericardial, Pleural fluids.  Feces . Urine. Vomit. Sputum.

12. Universal Precautions do not apply to: Tears. Nasal secretions. Sweat. Saliva.

13. PROTECTION EQUIPMENT BARRIER  Gloves : Should be worn for direct contact with blood or body fluids and for direct contact with non-intact skin or mucous membranes. Plastic aprons : These should be worn to protect from body fluids.  Eye protection : Goggles or some sort of eye protection (visor) should be worn to avoid conjunctival splash contamination. Spectacles are acceptable.  Masks : These are recommended to avoid blood or body fluids splashing into the mouth and nostrils.  Broken Skin : Cuts and abrasions on the hands and forearms should be covered with a waterproof dressing.

14. Safe Handling of Sharps Needles must never be re-sheathed or recapped. Must obtain assistance when taking blood or giving injections to uncooperative or confused patients. Never carry sharps by the hand , if transporting always place in an appropriate container. Needles must never be broken or bent prior to disposal. Needles must never be passed from hand to hand. When performing phlebotomy, cannulation or giving injections must wear appropriate disposable gloves. Never reuse a sharp.

15. Relevant pharmacology- anaesthetic agents The dose of thiopental should be reduced because a reduction in plasma proteins results in an increased unbound fraction of drug; the distribution half-life and consequently the duration of action are also prolonged. Sensitivity to the sedative and cardiorespiratory depressant effects of propofol is increased; hence the dose should be reduced. Etomidate may be used safely but offers little advantage over thiopental. Neuromuscular blocking drugs The metabolism of succinylcholine may be slowed because of reduced pseudocholinesterase concentrations, but in practice this gives few problems. There is an apparent resistance to non- depolarizing neuromuscular blockers (NMBs) in patients with liver disease, which may be due to an increased volume of distribution or to altered protein binding. Vecuronium and rocuronium, both steroid-based NMBs, have a prolonged elimination phase in severe liver disease. Atracurium and cisatracurium are suitable NMBs as they do not rely on hepatic excretion.

16. Morphine is perhaps best avoided in patients with decompensated liver failure as it may precipitate hepatic encephalopathy. Fentanyl, given in low doses, is suitable for intraoperative use as it does not have an active metab - olite and is renally excreted. However, in repeated or large doses, fentanyl will accumulate. Elimination of alfentanil is reduced in liver disease, its volume of distribution increased, and protein binding reduced by the lack of alpha-1-acid glycoprotein. Remifentanil is ideally suited to intraoperative use as it is metabolized by tissue and red cell esterases , which unlike plasma esterases are preserved in patients with severe liver disease. Opioids

17. Volatile anaesthetics All volatile anaesthetics reduce cardiac output and mean arterial pressure and thereby reduce liver blood flow. Isoflurane, sevoflur - ane , and desflurane undergo minimal hepatic metabolism and can be regarded as safe. Desflurane is probably the ideal volatile agent, being the least metabolized and providing the quickest emergence from anaesthesia. It also relatively preserves hepatic blood flow (it has minimal effects on the hepatic arterial buffer response) and cardiac output.

18. The Pugh modification of Child’s classification is used to estimate the risk of mortality in patients with liver disease undergoing surgery Child’s A – Low operative mortality <5% Child’s B – Moderate operative mortality 25% Child’s C – High operative mortality >50%

19. THANK YOU