PSH 2017

Peshawar Meeting November 2017

EVERYDAY CHALLENGES IN
CLINICAL PRACTICE
Objectives PSH 2017

Review basic principles of pre op assessment of patients

with liver disease
Effects of anesthesia and surgery on the liver
Estimation of operative risk
Risk associated with specific types of Surgery
Discuss strategies to optimize pre op management of liver
diseases
Choice of sedation for surgery
SCREENING FOR LIVER DISEASE BEFOREPSH 2017
SURGERY
HISTORY
prior blood transfusions
tattoos
illicit drug use
sexual promiscuity
family history of jaundice or liver disease
history of jaundice or fever following anesthesia
 alcohol use (current, prior and quantity)
complete review of current medications
Clinical features PSH 2017

 Increased abdominal girth

 Jaundice
Palmar erythema
Spider telangiectasias
 Splenomegaly
 Gynecomastia and testicular atrophy in men
 PSH 2017
Effects of anesthesia on the liver
Hepatic ischemia: elevated transaminases
Cirrhosis
Hyperdynamic circulation with decreased blood flow to
liver
More susceptible to hypoxemia and hypotension
Surgical factors contributing to hepatic ischemia:
Hypotension, hemorrhage, vasoactive medications
Positive pressure ventilation
Pneumoperitoneum during laparoscopic cases
 PSH 2017
Metabolism of medications

Volume of distribution of medications is increased in

cirrhotic patients.
Inhaled anesthetic choice
 Halothane dcrease hepatic blood flow and can cause
hepatotoxicity
Isoflurane, sevoflorane and desflorane has less effect on
hepatic blood flow and hepatotoxicity
 PSH 2017
Metabolism of medications

Atracurium/cisatracurium preferred—not excreted by liver

or kidney

Sedatives and narcotics can precipitate hepatic

encephalopathy and prolong periods of depressed
consciousness.
 PSH 2017

What are the postoperative

concerns
 PSH 2017
Coagulopathy

Decreased production of clotting factors

Depletion of vitamin K stores
Increased fibrinolytic activity
Thrombocytopenia
 PSH 2017
Ascites

Hepatic hydrothorax—respiratory complications

Wound complications
Hernia
 PSH 2017
Hepatic encephalopathy

Precipitating factors in post operative period

Volume contraction
Hypokalemia
Infection
Bleeding
Medications
Renal Dysfunction

Potential causes:
Intravascular volume depletion
Nephrotoxicity
ATN
Hepatorenal syndrome (HRS)
 PSH 2017
Pulmonary complications
Ascites and hepatic hydrothorax
Increased risk of aspiration
Pneumonia
ARDS
Ventilation dependence
Hepatopulmonary syndrome:
Triad of liver disease, increased AA gradient and
intrapulmonary shunting
Platypnea
EFFECTS OF ANESTHESIA AND SURGERYPSH
ON2017
THE LIVER
Depends upon:
Type of anesthesia used
specific surgical procedures
severity of liver disease.
Perioperative events
 hypotension
 sepsis
 Administration of hepatotoxic drugs
ESTIMATING SURGICAL RISK PSH 2017

 Appraisal of the severity of liver disease

The urgency of surgery (and alternatives to surgery)
Coexisting medical illness.
 Surgical risk assessment is less relevant if
immediate surgery is required to prevent death.
 Elective procedures
 Risk assessment
 Optimization of the patient's medical status
 Consideration of alternative approaches.
Study Design Flaws PSH 2017

Mostly small studies

Retrospective
Clinical experience
Arbitrary parameters
 PSH 2017

In a retrospective study of 261 patients (45 with cirrhosis

and 216 matched controls without cirrhosis) undergoing
cardiac surgery between 1992 and 2009,
 CP < 8 : 95 % survival rate at 90 days
 CP > 8 : 30 % survival rate at 90 days
MELD score PSH 2017

MELD is supplanting the CP classification as the principal

method for determining surgical risk
The MELD score, American Society of Anesthesiologists
(ASA) class, and age predicted mortality in a study of 772
patients with cirrhosis who underwent major digestive,
orthopedic, or cardiovascular surgery.
The MELD score was the best predictor of 30- and 90-day
mortality. Mortality at 30 days ranged from 6 percent
(MELD score, <8) to more than 50 percent (MELD score,
>20) and correlated linearly with the MELD score.
 PSH 2017

Increased risk of mortality up to 90 days postoperatively

Mortality rates
MELD <7: 5.7%
MELD 8-11: 10.3%
MELD 12-15: 25.4%
ASA class IV adds 5.5 MELD points. ASA class V = 100%
mortality
 PSH 2017

 MELD < 10 : elective surgery

 MELD 10 to 15 : elective surgery with caution
 MELD >15 : should not undergo elective surgery
 PSH 2017

Obstructive jaundice —
Increased risk of perioperative complications
Infections
stress ulceration
DIC
wound dehiscence
renal failure
 PSH 2017

An overall mortality rate of 9 percent was found in a large

retrospective study that included 373 patients undergoing
surgery for obstructive jaundice.
Multivariate analysis identified three predictors of
postoperative mortality:
An initial hematocrit value <30 percent
An initial serum bilirubin level >11 mg/dL (200 micromoles/L)
A malignant cause of obstruction (eg, pancreatic carcinoma
or cholangiocarcinoma)
All three factors +ive Mortality 60 %
 PSH 2017

A number of interventions have been attempted to reduce

morbidity and mortality in these patients:
Perioperative administration of broad-spectrum intravenous
antibiotics
External biliary drainage via a transhepatic approach
Endoscopic biliary drainage
 PSH 2017

Limited evidence suggests that the administration of

bile salts or lactulose to patients with obstructive
jaundice can prevent both the endotoxemia and the
exaggerated renal vasoconstriction
 PSH 2017

Cardiac surgery —
 Cardiac surgery is associated with increased mortality in
patients with cirrhosis compared to other surgical
procedures
 PSH 2017

9 studies involving 210 patients with cirrhosis

Mortality : 17 %.
 CP A: 5%
CP B : 35%
CP C : 70%
 MELD score has not been adequately studied as a
prognostic tool for patients undergoing cardiac surgery.
 PSH 2017

 Risk factors for hepatic decompensation

 total time of cardiopulmonary bypass
 use of nonpulsatile as opposed to pulsatile
cardiopulmonary bypass
need for perioperative pressor support
Thus, the least invasive options
Angioplasty,
Valvuloplasty
Minimally invasive revascularization techniques, should
 PSH 2017

Hepatic resection —
RESIDUAL VOLUME NEEDED
Normal Liver 25%
Cirrhotic liver 40%
Risk factors for hepatic decompensation
CTP
MELD
BILIRUBIN
PT
Portal Hypertension
 PSH 2017

A database study of 587 patients who underwent hepatic

resection concluded that the Child-Turcotte-Pugh score
and ASA score were better predictors of morbidity and
mortality than the MELD

Schroeder et al Ann Surg 2006; 243:373.

OPTIMIZING MEDICAL THERAPY
COAGULOPATHY PSH 2017

Management of haemostatic abnormalities in patients with

cirrhosis
 optimize the platelet count
 optimize fibrinogen level
 optimize renal function
 avoid the INR values to guide therapy
A prolonged bleeding time can be treated
with desmopressin (DDAVP).
Optimal surgical technique and maintenance of low
PSH 2017
PSH 2017
PSH 2017
PSH 2017