What are the risks of operating on a patient with hyperbilirubinemia (elevated total bilirubin level of 9 mg/dL)?

From the Guidelines

Operating on a patient with a total bilirubin of 9 mg/dL is strongly discouraged for elective procedures due to the significant risk of perioperative complications and high mortality rates. This elevated bilirubin level indicates substantial liver dysfunction, which can lead to several complications including excessive bleeding due to impaired clotting factor production, poor wound healing, increased risk of infection, and heightened sensitivity to anesthetics 1. According to the ERAS society recommendations, preoperative biliary drainage is recommended for cholestatic liver patients with bilirubin levels above 50 mmol/l, and surgery should ideally not be performed until bilirubin levels drop below this threshold 1.

In emergency situations where surgery cannot be delayed, careful preoperative optimization is crucial, including vitamin K administration, possible fresh frozen plasma transfusion to correct coagulopathy, and consideration of ERCP with stenting if biliary obstruction is present. The anesthesia team should use medications that don't require extensive hepatic metabolism, and postoperative monitoring should be intensified 1. The specific risk depends on the cause of hyperbilirubinemia (obstructive vs. hepatocellular), the type of surgery planned, and the patient's overall condition.

Key considerations for managing such patients include:

• Preoperative counseling and optimization of the patient's condition
• Careful selection of anesthetic medications
• Close monitoring of the patient's hemodynamic status and coagulation parameters
• Consideration of delayed kidney transplantation in cases of combined liver-kidney transplantation, as hyperbilirubinemia can increase the risk of acute kidney injury and renal dysfunction of the kidney allograft 1.

Mortality rates for major surgeries in patients with this degree of jaundice can range from 10-40%, with higher rates in those with concurrent renal dysfunction or malnutrition. Therefore, a thorough evaluation of the patient's overall condition and careful planning of the surgical procedure are essential to minimize the risks associated with surgery in patients with elevated bilirubin levels.

From the Research

Risk Assessment of Operating on a Patient with Total Bilirubin of 9

• The risk of operating on a patient with a total bilirubin level of 9 is significant, as elevated bilirubin levels have been associated with increased mortality rates in critically ill patients 2.
• A study published in 2002 found that each 1.0-mg/dL increase in total bilirubin was associated with a 40% greater odds of 30-day mortality in patients undergoing transjugular intrahepatic portosystemic shunt (TIPS) creation 3.
• Another study published in 2018 discussed the pathophysiological consequences of obstructive jaundice, including proinflammatory cytokine production, coagulation disorders, and multiple organ dysfunction syndrome, which can increase the risk of mortality in patients with elevated bilirubin levels 4.
• The association between serum total bilirubin level and hospital mortality rate was also investigated in a retrospective study published in 2021, which found that patients with serum total bilirubin levels ≥ 2 mg/dL had a higher hospital mortality rate compared to those with levels < 2 mg/dL 2.
• Additionally, a study published in 2013 found that vitamin K administration did not significantly improve coagulation parameters in patients with liver disease, which may be relevant to patients with elevated bilirubin levels 5.
• The diagnosis and evaluation of hyperbilirubinemia were reviewed in a 2017 study, which emphasized the importance of a careful history and physical examination, followed by imaging assessment of the biliary tree and liver 6.

Key Findings

• Elevated bilirubin levels are associated with increased mortality rates in critically ill patients 2.
• Each 1.0-mg/dL increase in total bilirubin is associated with a 40% greater odds of 30-day mortality in patients undergoing TIPS creation 3.
• Obstructive jaundice can lead to proinflammatory cytokine production, coagulation disorders, and multiple organ dysfunction syndrome, increasing the risk of mortality 4.
• Vitamin K administration may not significantly improve coagulation parameters in patients with liver disease 5.