Expert: Ronald Levy, M.D. - 7/15/2011

Question
Dear Dr. Levy,
I have a close acquaintance who recently had shoulder surgery.
55yr. old male,20#overwt./ healthy. A Hx.previously one surgery 5 yrs. ago for hernia repair w/o complications.
A general anesthetic using desflurane, and IV fentanyl was used. as well as a nerve block.
surg. was done in 55 minutes without complications.He maintained a sinus bradycardia throughout the procedure of 38-52bpm
post-op care was rushed and he was sent home 2 hrs after surgery, still lethargic, and vomiting.
At his home I assessed him the night of surgery, and he had a B/P of 102/64,Hr 52 and O2 reading of 72% on RA. I placed him on 3L of oxygen made him deep breath and cough and gradually weaned him off oxygen, over the next 4 hrs. I waited for bowel sounds to begin and then gradually introduced clear liquids.
Over the next 3 weeks he repeatedly complained of severe nausea,anorexia,and fatigue. He had taken one percocet for pain 2 days post-op otherwise Motrin. He refused to be taken back to the ER the night of surgery or afterwards for further evaluation. We live in a small rural area.The hospital is a 49 bed facility and employs only CRNA's.
I was finally able to convince this person to call his dr. for advice. After many evaluations and phone calls etc. the dr. thinks he had an mild,acute drug induced liver toxicity/hepatitis from the anesthetic.
He had lab work drawn, with a metabolic profile and CBC one week post=op. Unfortunately the CBC, and LFT's were missed. he had an elevated glucose (fasting of 115, otherwise Na, K and Cl and Mg were normal.
tomorrow his dr. has reordered the LFts as well as bilirubin.
and CBC. the diagnosis of liver toxicity is speculation at this point.
I have several questions.
Presently he is 3 weeks post-op and is finally starting to feel better. If he did have the blood drawn tomorrow, and the LFT's come back normal, would that eliminate the possibility of a drug induced hepatitis? or would have had all ready recovered?   
second question? can you have liver inflammation? from lack of oxygen and poor perfusion post-op?
At what HR do the nurse anesthetists(during surgery) consider giving atropine for a bradycardia?
last question? what is the recovery time for an anesthetic induced liver toxicity?
Is there anything he could be doing to enhance his recovery besides rest,fluids. etc.?
He has returned to work as a civil engineer but tires easily.
he previously exercised every day for one hour and wants to return to that but for now is walking 2 miles each day with his dog. Nausea has only in the last 2 days started to subside.
Thanks so much for your input.
I am an older retired nurse practitioner, who is his friend.
Gone are the days when we kept. pts. 2-3 days post-op.

Answer
If he did have the blood drawn tomorrow, and the LFT's come back normal, would that eliminate the possibility of a drug induced hepatitis?

>>>>    The incidence of anesthesia induced hepatitis is exceedingly small so my guess is that this is not the problem here. If his LFTs are normal, I would think that would rule out this dx.
  
second question? can you have liver inflammation? from lack of oxygen and poor perfusion post-op?

>>>>    Not isolated. If that were the case, the kidneys and heart would suffer more than the liver. Remember that the liver has a dual blood supply (central venous and portal systems) so is used to a lower pO2.

At what HR do the nurse anesthetists(during surgery) consider giving atropine for a bradycardia?

>>>>    There is no specific heart rate. If the vital signs are stable and his normal resting HR is in the 50s, they would not treat it.

last question? what is the recovery time for an anesthetic induced liver toxicity?

>>>>   Again, since this is rare, I don't think there is a good answer for you.

Is there anything he could be doing to enhance his recovery besides rest,fluids. etc.?

>>>>  Bed rest is probably the best option. It is not unusual to feel tired for weeks after surgery (unrelated to aensthesia).

Ronald Levy, MD
Professor of Anesthesiology
UTMB-Galveston