Preparing jaundiced patients for surgery

Patients with obstructive jaundice are particularly prone to developing renal failure after surgery, perhaps from the toxic effect of bilirubin and any concomitant sepsis. In practice this means that good urine output must be maintained in such patients around the time of surgery.

Pre-op preparation

• Avoid morphine in the premedication.
• Give antibiotic prophylaxis and treat sepsis to decrease risk of endotoxaemia.
• Insert IV line and give 1L of 0.9% saline over 30min-1h following pre-med (unless the patient has heart failure), to produce a moderate diuresis perioperatively. A loop diuretic e.g. furosemide may be needed to ensure disuresis.
• Insert urinary catheter.
• A 'renal' dose dopamine (2-5µg/kg/min) IVI may be indicated.
• Check clotting and consider giving prophylactic vitamin K, even if normal.

During surgery

Measure urine output hourly and give 0.9% saline IV to match the urine output.

For 48h after surgery

• Measure urine output every 2h; measure U&E daily.
• Give 0.9% saline at rate to match urine output and fluid lost e.g. through the NGT; give 2L of dextrose-saline every 24h.
• Consider furosemide if urine output is poor despite adequate hydration.
• Give 20mmol of K per litre of fluid after 24h post-op if urine output good.