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Ch35. Anesthesia for Patients with
Liver Disease
R1
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Liver has remarkable functional reservez Hepatic disease clinical manifestation extensive
damage
z little reserve marginal patient OR
further hepatic decompensation overt hepatic failure
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HEPATITIS
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ACUTE HEPATITIS
z viral infection, drug reaction, exposure tohepatotoxin
z Acute hepatocellular injury with variable amounts of cell
necrosis
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Viral hepatitis
Transmissionz Hepatitis A & E : oral-fecal route
z Hepatitis B & C : percutaneously & by contact with body fluids
z Hepatitis D : host hepatitis B virus
Clinical manifestionsz 1- to 2-week mild prodromal illness
~ Fatigue, malaise, low-grade fever, vausea, vomiting
z Jaudice , ~ 2-12 wks , 4 mns
~ Hepatitis B & C : cholestasis, fulminant hepatic failure
Prognosisz
Chronic active hepatitis : hepatitis B 3-10%, C 50%z Asymptomatic infectious carriers
~ HBsAg(+) Pt 0.3-30%, hepatitis C 0.5-1%(hepatitis C viral RNA )
Immunizationz Highly effective against hepatitis B infection
z Postexposure prophylaxis with hyperimmune globulin is effective for hepatitis B
z Hepatitis C vaccine, prophylaxis
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Drug-induced hepatitis
Cause
z Direct dose-dependent toxicity of adrug
z Idiosyncratic drug reaction
Alcoholic hepatitis
z Chronic alcohol ingestion fattyinfiltration hepatomegaly
~ Impaired fatty acid oxidation
~ Increased uptake & esterification of
fatty acid~ Diminished lipoprotein synthesis &
secretion
Acetaminophen ingestion
z Ingestion of 25G or more fatalfulminant disease
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Preoperative considerations
Elective surgery acute hepatitis resolve z LFT normalization
z Periop. Morbidity(12%), mortality(10% with laparotomy)
z Acute alcohol toxicity : greatly complicated
~ alcohol withdrawal mortality rate 50% Lab. Evaluationz BUN, s-electrolyte, creatinine, glucose, transaminases, alkaline phosphatase,
albumin, PT, platelet count
z Alcoholic hepatitis ALT AST z PT : best indicator of hepatic synthetic function
~ Vit. K PT 3 sec (INR >1.5) : severe hepatic dysfunction
z drug exposure, transfusion, prior enesthetics
z Dehydration & electrolyte abNL
z Coagulopathy Vit. K, FFP z Premedi
~ Acute withdrawal alcoholic Pt. benzodiazepine & thiamine
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Intraoperative considerations
Goalz Preserve existing hepatic function
z Avoid factors that may be detrimental to the liver
Alcoholic Ptz Cross-tolerance to anesthetics
z Close cardiovascular monitoring~ Alcohol cardiac depression, alcoholic cardiomyopathy
IV inhalation anesthetics z Standard induction doses of IV agents
~ Metabolism or excretion redistribution
Isoflurane is the volatile agent of choicez Hepatic blood flow
z Hepatic blood flow ~ Hypotension, excessive sympathetic activation, high mean airway pr.
z Coagulopathy regional anesthetia ~ Hypotension
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CHRONIC HEPATITIS
Persistent hepatic inflammation for longer than 6 monthsz Evidenced by elevated serum aminotransferases
Liver biopsy 1. Chronic persistent hepatitis
~ cellular architecture portal tract chronic inflammation
2. Chronic lobular hepatitis~ Resolve acute hepatitis, but recurrent exacerbations
~ Hepatic lobule inflammation necrosis foci
3. Chronic active hepatitis~ chronic hepatic inflammation
~ LC : 20-50%
~ hepatitic B or C sequelae
~ Fatigue, recurrent jaundice
~ Only a mild elevation in serum aminotransferase activityz Often correlate poorly with disease severity
~ Chr. hepatitis B or C
Anesthetic managementz Chronic persistent or lobular hepatitis acute hepatitis
z Chronic active hepatitis cirrhosis
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CIRRHOSIS
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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 Hepatocyte necrosis, fibrosis, nodular regeneration
z , portal venous flow
z Signs Symptoms disease severity
~ Jaundice, ascites
~ Spider angiomas, palmar erythema, gynecomastia, splenomegalyz 3 Major complications
~ Variceal hemorrhage from portal hypertension
~ Intractable fluid retention in ascites, hepatorenal syndrome
~ Hepatic encephalopathy, coma
z 10% spontaneous bacterial peritonitis, HCC
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Preoperative considerationsb. hematological manifestations
z Anemia
~ Blood loss, RBC destruction , bone barrow
suppression, nutritional deficiencies
z Thrombocytopenia, leukopenia~ Congestive splenomegaly (from portal HTN)
z Coagulation factor deficiencies
~ Decreased hepatic synthesis
Preop. Blood transfusion
z Nitrogen load encephalopathy
z coagulopathy
~ FFP, cryoprecipitate
~ platelet < 100,000/ platelet
transfusion
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Preoperative considerationsc. circulatory manifestations
Cirrhosis : hyperdynamic circulatory stateArteriovenous shunt
z Systemic & pulm. circulation
z Anemia blood viscosity filling
pr. systemic vascular resistance
cardiac output cirrhotic cardiomyopathy
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Preoperative considerationsd. respiratory manifestations
Hyperventilation
z
Primary respiratory alkalosis Hypoxemia
z Rt-to-Lt shunting (up to 40% of cardiac
output)
z Shunt pulm. A-V communications, V-Q
mismatching Ascites diaphragmatic elevation
lung volume
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Preoperative considerationse. renal manifestations and fluid balance
Ascites
z Portal HTN hydrostatic pr. intestine peritoneal cavity fluid transudation
z Hypoalbuminemia plasma oncotic pr. fluid transudation
z Protein-rich lymphatic fluid serosal surface ofliver
z 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)
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Preoperative considerations
e. renal manifestations and fluid balance
Hepatorenal syndrome
z Progressive oliguria, avid sodium retention,azotemia, intrractable ascites
z Very high mortality rate
z Liver transplantation
Judicious periop. fluid managementz diuresis
z Acute intravascular fluid deficit colloid infusion
z Ascites pph. Edema diuresis 1/d
z Loop diuretics~ Bed rest, sodium restriction(
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Preoperative considerationsf. central nervous system manifestations
Hepatic encephalopathyz Alterations in mental status
z With fluctuating neurological signs~ Asterixis, hyperreflexia, inverted plantar reflex)
z EEG changes
~ Symmetric high-voltage, slow-wave activityz ICP
Factors precipitate hepatic encephalopathyz G-I cleeding
z Increased dietary protein intake
z Hypokalemic alkalosis (from vomiting or diuresis)
z Infectionsz Worsening liver function
aggressive z Oral lactulose 30-50mL every 8h or neomycin
500mg every 6h
reduce intestinal ammonia absorptionz Avoidance of sedatives
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Intraoperative considerations
Hepatitis B or C carrier : blood & body fluid
Drug responsesz Unpredictable for response to anesthetic agents
z NMBAs highly ionized drug volume of distribution
~ Hepatic elimination (pancuronium, rocuronium, vecuronium) Anesthetic techniquez Hepatic a. blood flow
z Regional anesthesia : thrombocytopenia, coagulopathy ~ Hypotension
z General anesthesia~ 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)
z Preoxygenation & rapid-sequence induction with cricoid pressure
z Unstable pt. & active bleeding ~ Awake intubation
~ Rapid-sequence induction with cricoid pr., using ketamine (or etomidate) & succinylcholijne
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Intraoperative considerations (2)
Monitoringz Vasopressin 5-lead ECG MI
z ABGA : acid-base status
z Large Rt-to-Lt intrapulm. Shunt~ Nitrous oxide
~ PEEP : V-Q mismatch, hypoxemia
z Intraarterial pr. Monitoring
z Intravascular volume status : CVP, pulm. a. pr. Monitoring
z Urinary output
Fluid replacement
z intravascular volume & urinary output z Colloid iv fluid(albumin)
~ Sodium overload , oncotic pressure
~ Ascitic fluid iv colloid fluid replacement
z Transfusion~ citrate toxicity
z Hypocalcemia
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HEPATOBILIARY DISEASE
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Hepatobiliary disease
Cholestasis
z Progressive jaundice, dark urine with pale stool, pruritus
z Extrahepatic obx of biliary tract : m/c cause
~ Gallstone, stricture, tumor in common hepatic ductz Intrahepatic cholestasis
~ Viral hepatitis, idiosyncratic drug reaction (phenothiazine, oral
contraceptives)
Cholelithiasis
z Cholecystitis : RUQ tenderness, fever, leukocytosisz Cholangitis : chill or high fever
z Acute cholecystitis 75% medical treatment 2-7
z 5-10% acalculous cholecystitis
~ Serious trauma, burns, prolonged labor, major surgery, critical illness
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Hepatobiliary disease (2)
Preoperative considerations
z Acute cholecystitis medically stabilized cholecystectomy (LC)
~ Nasogastric suction, iv fluids, antibiotics, opioid analgesics
z Acalculous cholecystitis~ critically ill pt. gangrene & perf.
~
z Extrahepatic biliary obx. vit.K deficiency
~ Vit.K , PT FFP
z
Generous preop. HydrationIntraoperative considerations
z Intraop. Cholangiogram opioid
~ False-positive
~ Opioid-induced sphincter spasm naloxone or glucagon
z
Renal elimination
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HEPATIC SURGERY
Common hepatic procedures
z Repair of lacerations, drainage of abscesses, resections for
tumors
Hepatic surgery
z Multiple large-bore iv catheters
z Fluid(blood) warmers
z Arterial pr., CVP monitoring
z Antifibrinolytics
~ Aprotinin, -aminocaproic acid, tranexamic acid
Postop Cx
z Bleeding, sepsis, hepatic dysfunction
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