Ch35.

Anesthesia for Patients with Liver Disease

R1

Liver has remarkable functional reserve

z

Hepatic disease clinical manifestation extensive damage little reserve marginal patient OR
further hepatic decompensation overt hepatic failure

HEPATITIS

ACUTE HEPATITIS

viral infection, drug reaction, exposure to hepatotoxin Acute hepatocellular injury with variable amounts of cell necrosis

Viral hepatitis
Transmission
z z z

Hepatitis A & E : oral-fecal route Hepatitis B & C : percutaneously & by contact with body fluids Hepatitis D : host hepatitis B virus 1- to 2-week mild prodromal illness
~

Clinical manifestions
z

Fatigue, malaise, low-grade fever, vausea, vomiting

Jaudice
~ ~

2-12 wks , 4 mns Hepatitis B & C : cholestasis, fulminant hepatic failure

Prognosis
z z

Chronic active hepatitis : hepatitis B Asymptomatic infectious carriers

~

3-10%, C
0.5-1%

50%
)

HBsAg(+) Pt

0.3-30%, hepatitis C

(hepatitis C viral RNA

Immunization
z z z

Highly effective against hepatitis B infection Postexposure prophylaxis with hyperimmune globulin is effective for hepatitis B Hepatitis C vaccine, prophylaxis

Drug-induced hepatitis
Cause
z

Direct dose-dependent toxicity of a drug Idiosyncratic drug reaction Chronic alcohol ingestion fatty infiltration hepatomegaly
~ ~

Alcoholic hepatitis
z

Impaired fatty acid oxidation Increased uptake & esterification of fatty acid Diminished lipoprotein synthesis & secretion

Acetaminophen ingestion
z

Ingestion of 25G or more fulminant disease

fatal

Preoperative considerations
Elective surgery
z z z

acute hepatitis

resolve

LFT normalization Periop. Morbidity(12%), mortality(10% with laparotomy) Acute alcohol toxicity : greatly complicated
~

alcohol withdrawal

mortality rate 50%

Lab. Evaluation
z z z

BUN, s-electrolyte, creatinine, glucose, transaminases, alkaline phosphatase, albumin, PT, platelet count Alcoholic hepatitis ALT AST PT : best indicator of hepatic synthetic function
~

Vit. K

PT 3 sec

(INR >1.5) : severe hepatic dysfunction

z z z z

drug exposure, transfusion, prior enesthetics Dehydration & electrolyte abNL Coagulopathy Vit. K, FFP Premedi
~

Acute withdrawal

alcoholic Pt.

benzodiazepine & thiamine

Intraoperative considerations
Goal
z z

Preserve existing hepatic function Avoid factors that may be detrimental to the liver Cross-tolerance to anesthetics Close cardiovascular monitoring
~

Alcoholic Pt
z z

Alcohol

cardiac depression, alcoholic cardiomyopathy

IV
z
~

inhalation anesthetics
Standard induction doses of IV agents
Metabolism or excretion redistribution

Isoflurane is the volatile agent of choice

z z

Hepatic blood flow Hepatic blood flow

~

Hypotension, excessive sympathetic activation, high mean airway pr.

Coagulopathy
~

regional anesthetia

Hypotension

CHRONIC HEPATITIS
Persistent hepatic inflammation for longer than 6 months
z

Evidenced by elevated serum aminotransferases Chronic persistent hepatitis

~

Liver biopsy
1.

cellular architecture

portal tract

chronic inflammation

2.

Chronic lobular hepatitis

~ ~

Resolve acute hepatitis, but recurrent exacerbations Hepatic lobule inflammation necrosis foci chronic hepatic inflammation LC : 20-50% hepatitic B or C sequelae Fatigue, recurrent jaundice Only a mild elevation in serum aminotransferase activity
z

3.

Chronic active hepatitis

~ ~ ~ ~ ~ ~

Often correlate poorly with disease severity

Chr. hepatitis B or C

Anesthetic management
z z

Chronic persistent or lobular hepatitis acute hepatitis Chronic active hepatitis cirrhosis

CIRRHOSIS

Cirrhosis
m/c cause in US : alcohol
z

chronic active hepatitis, chronic biliary inflammation or obx., chronic Rt-sided CHF, autoimmune hepatitis, hemochromatosis, Wilsons disease, 1-antitrypsin deficiency, nonalcoholic steatohepatitis, cryptogenic cirrhosis , Signs Symptoms
~ ~

Hepatocyte necrosis, fibrosis, nodular regeneration

z z

portal venous flow disease severity

Jaundice, ascites Spider angiomas, palmar erythema, gynecomastia, splenomegaly Variceal hemorrhage from portal hypertension Intractable fluid retention in ascites, hepatorenal syndrome Hepatic encephalopathy, coma

3 Major complications
~ ~ ~

10%

spontaneous bacterial peritonitis,

HCC

Preoperative considerations
a. gastrointestinal manifestations
Portal-systemic venous collateral channels
z

Gastroesophageal
~

Massive bleeding from varices : Mj cause of morbidity & mortality

z

Blood loss, blood hepatic encephalopathy

nitrogen load

q
z

: IV fluid, blood product

Vasopressin, somatostatin, propranolol, balloon tamponade(Sengstaken-Blakemore tube), endoscopic sclerosis IV NTG : vasopressin CHF or MI Percutaneous transjugular intrahepatic portosystemic shunts (TIPS) Selective shunts(distal splenorenal) : varix , encephalopathy

z z

z z z

Hemorrhoidal Periumbilical retroperitoneal

Preoperative considerations
b. hematological manifestations
z

Anemia
~

Blood loss, RBC destruction , bone barrow suppression, nutritional deficiencies Congestive splenomegaly (from portal HTN) Decreased hepatic synthesis

Thrombocytopenia, leukopenia
~

Coagulation factor deficiencies

~

Preop. Blood transfusion

z

Nitrogen load coagulopathy

encephalopathy

z
~ ~

FFP, cryoprecipitate platelet < 100,000/ transfusion

platelet

Preoperative considerations
c. circulatory manifestations

Cirrhosis : hyperdynamic circulatory state Arteriovenous shunt

z z

Systemic & pulm. circulation Anemia blood viscosity filling pr. systemic vascular resistance cardiac output cirrhotic cardiomyopathy

Preoperative considerations
d. respiratory manifestations

Hyperventilation
z

Primary respiratory alkalosis Rt-to-Lt shunting (up to 40% of cardiac output) Shunt pulm. A-V communications, V-Q mismatching

Hypoxemia
z

Ascites diaphragmatic elevation lung volume

Preoperative considerations
e. renal manifestations and fluid balance
Ascites
z

Portal HTN hydrostatic pr. intestine peritoneal cavity fluid transudation Hypoalbuminemia plasma oncotic pr. fluid transudation Protein-rich lymphatic fluid serosal surface of liver Renal sodium retention
~

e Underfillingf

theory : effective plasma volume

e Oveflowf theory : renal sodium retention transudation ascites

Cirrhosis & ascites

z

Renal perfusion , intrarenal hemodynamics , proximal & distal sodium reabsorption , free water clearance hyponatremia (dilutional), hypokalemia (excessive urinary potassium losses)

Preoperative considerations
e. renal manifestations and fluid balance
Hepatorenal syndrome
z

z z

Progressive oliguria, avid sodium retention, azotemia, intrractable ascites Very high mortality rate Liver transplantation u diuresis Acute intravascular fluid deficit Ascites pph. Edema 1 /d Loop diuretics
~

Judicious periop. fluid management

z z

colloid infusion diuresis

Bed rest, sodium restriction(<2gNaCl/d), spironolactone

z z z

Hyponatremia (<120mEq/L) water restriction Potassium deficit Prophylactic periop. Mannitol infusion may be effective in preventing renal failure

Preoperative considerations
f. central nervous system manifestations
Hepatic encephalopathy
z z

Alterations in mental status With fluctuating neurological signs

~

Asterixis, hyperreflexia, inverted plantar reflex)

z
~

EEG changes
Symmetric high-voltage, slow-wave activity

ICP G-I cleeding Increased dietary protein intake Hypokalemic alkalosis (from vomiting or diuresis) Infections Worsening liver function

Factors precipitate hepatic encephalopathy

z z z z z

aggressive
z

Oral lactulose 30-50mL every 8h or neomycin 500mg every 6h reduce intestinal ammonia absorption Avoidance of sedatives

Intraoperative considerations
Hepatitis B or C carrier : blood & body fluid Drug responses
z z

Unpredictable for response to anesthetic agents NMBAs highly ionized drug volume of distribution
~

Hepatic elimination

(pancuronium, rocuronium, vecuronium)

Anesthetic technique
z z

Hepatic a. blood flow Regional anesthesia : thrombocytopenia, coagulopathy

~

Hypotension Induction : barbiturate or propofol induction Maintenance : isoflurane in oxygen or oxygen-air mixture Opioid supplementation : half-life prolonged resp. depression Cisatracurium : NMBA of choice (unique nonhepatic metabolism)

General anesthesia
~ ~ ~ ~

z z

Preoxygenation & rapid-sequence induction with cricoid pressure Unstable pt. & active bleeding
~ ~

Awake intubation Rapid-sequence induction with cricoid pr., using ketamine (or etomidate) & succinylcholijne

Intraoperative considerations (2)

Monitoring
z z z

Vasopressin 5-lead ECG ABGA : acid-base status Large Rt-to-Lt intrapulm. Shunt
~ ~

MI

Nitrous oxide PEEP : V-Q mismatch, hypoxemia q

z z z

Intraarterial pr. Monitoring Intravascular volume status : CVP, pulm. a. pr. Monitoring Urinary output intravascular volume & urinary output Colloid iv fluid(albumin)
~ ~

Fluid replacement
z z

Sodium overload Ascitic fluid

, oncotic pressure iv colloid fluid replacement

Transfusion
~
z

citrate toxicity
Hypocalcemia

HEPATOBILIARY DISEASE

Hepatobiliary disease
Cholestasis
z z

Progressive jaundice, dark urine with pale stool, pruritus Extrahepatic obx of biliary tract : m/c cause
~

Gallstone, stricture, tumor in common hepatic duct Viral hepatitis, idiosyncratic drug reaction (phenothiazine, oral contraceptives)

Intrahepatic cholestasis
~

Cholelithiasis
z z z z

Cholecystitis : RUQ tenderness, fever, leukocytosis Cholangitis : chill or high fever Acute cholecystitis 75% medical treatment 2-7 5-10% acalculous cholecystitis
~

Serious trauma, burns, prolonged labor, major surgery, critical illness

Hepatobiliary disease (2)

Preoperative considerations
z

Acute cholecystitis cholecystectomy

~

medically stabilized (LC)

Nasogastric suction, iv fluids, antibiotics, opioid analgesics critically ill pt. gangrene & perf.

Acalculous cholecystitis
~ ~

Extrahepatic biliary obx.

~

vit.K deficiency
FFP

Vit.K

, PT

Generous preop. Hydration Intraop. Cholangiogram

~ ~

Intraoperative considerations
z

opioid
naloxone or glucagon

False-positive Opioid-induced sphincter spasm

Renal elimination

HEPATIC SURGERY
Common hepatic procedures
z

Repair of lacerations, drainage of abscesses, resections for tumors Multiple large-bore iv catheters Fluid(blood) warmers Arterial pr., CVP monitoring Antifibrinolytics
~

Hepatic surgery
z z z z

Aprotinin,

-aminocaproic acid, tranexamic acid

Postop Cx
z

Bleeding, sepsis, hepatic dysfunction