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PSH 2017

Peshawar Meeting November 2017

EVERYDAY CHALLENGES IN
CLINICAL PRACTICE
PSH 2017
Objectives

• 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
PSH 2017
SCREENING FOR LIVER
DISEASE BEFORE
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)
PSH 2017
Clinical features

• 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
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
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
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
PSH 2017
EFFECTS OF ANESTHESIA
AND SURGERY ON THE
LIVER
• Depends upon:
– Type of anesthesia used
– specific surgical procedures
– severity of liver disease.
– Perioperative events
 hypotension
 sepsis
 Administration of hepatotoxic drugs
PSH 2017
ESTIMATING SURGICAL
RISK

• 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
PSH 2017
Study Design Flaws

• 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
PSH 2017
MELD score

• 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-
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%
PSH 2017
PSH 2017

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