1. Anesthesia in a patient with Gilbert syndrome.Case report Revista Brasilia de Anesthesiologica june 2004

2. Introdoction Is a chronic benign disease 6% incidence,more frequent in males,autosomal dominant with variable penetration. Patients have jaundice through stress,exercise,fasting,active mens.bleeding. There is a glucoronyl transferase deficiency. Jaundice occures when bilirubin is above2.5 to 3mg/dl.

3. Case Report: Caucasian female 22 years old, known case of Gilbert since she was 12. Patient was admitted for laparoscopic correction of GE reflux. Her history : jaundice after prolonged fasting, after insomnia & during active mens.cycles. Preanesthetic approach:8h NPO,surgery scheduled for the first morning without any permedication.

4. Monitoring: EKG, Pulse oxymetry, NIBP, Capnography Infusion of DW 5% & IV omeprazol 40mg & ondansetron 4mg (before induction) GA induced 30 minutes after, pofol 150mg, Succ. 50mg & alfentanil 2500mcg.

5. Tracheal intubation: 6.5 cuffed pvc, using sellick manuver with fast track. Maintenance: Lactated ringer, isoflurane, atracurium,oxygen. Ketoprofen(100mg) & Dexamethasone 10mg was administered after extubation for postoperative analgesia.

6. Surgery lasted 120 minutes & emergence was calm. Patient was discharged 3 days later without complications.

7. Discussion: The group of biochemical reactions making drugs polar,hydrosoluble & easily excreted occure in the liver. During metabolism the liver is able to include some endogenous substances, such as glucoronic acid.

8. Due to low glucoronidase in Gilbert, there is the risk of anesthetic toxicity. Its important for the anesthesiologist to understand conditions leading to low glucoronyl transferase activity in Gilbert:

9. 1. To minimize fasting & waiting stress: surgery be performed in the first morning (admit patients in the day of surgery). 2. Glucose infusion before surgery. 3. To avoid elective surgery during mens cycles. 4. To assure satisfactory postoperative analgesia. 5. To refuse hepatotoxic drugs.

10. Contnued: In our case glucose was not maintained during surgery because surgery itself is a stressor with increased glycemia. To minimize the risk of reflux, we decided fast-track induction & proton pomp blocker associated with ondancetrone.

11. Halothane was not used because of high liver metabolism(20%) & for its potential to cause postoperative jaundice. Isoflurane has 0.2% liver metabolism. All volatiles decrease total liver blood flow & this is minimum with isoflurane.

12. Thiopental & ketamine change LFTs dose dependently.& may impair postoperative investigation of jaundice. Etomidate may lead to adrenal failure. Propofol & Remifentanil should be preferred for TIVA.

13. Causes of postoperative jaundice: Major hematomas,transfusion,underlying liver diseas,intrahepatic cholestasis, Postoperative pancreatitis, retained CBD stones & Gilbert.

14. Thank you for your attention Many thanks to: Dr Shahram Nasernejad.