PSH 2017

Peshawar Meeting November 2017

EVERYDAY CHALLENGES IN
CLINICAL PRACTICE
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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
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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)
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Clinical features

• Increased abdominal girth

• Jaundice
• Palmar erythema
• Spider telangiectasias
• Splenomegaly
• Gynecomastia and testicular atrophy in men
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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
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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
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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.
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• What are the postoperative

concerns
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Coagulopathy

• Decreased production of clotting factors

• Depletion of vitamin K stores
• Increased fibrinolytic activity
• Thrombocytopenia
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Ascites

• Hepatic hydrothorax—respiratory complications

• Wound complications
• Hernia
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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)
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Pulmonary complications

• Ascites and hepatic hydrothorax

• Increased risk of aspiration
• Pneumonia
• ARDS
• Ventilation dependence
• Hepatopulmonary syndrome:
Triad of liver disease, increased AA gradient and
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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
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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
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Study Design Flaws

• Mostly small studies

• Retrospective
• Clinical experience
• Arbitrary parameters
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• 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
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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-
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• 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%
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PSH 2017