Anaesthetic management of Liver disease

Dr.K. Sailaja P.G. Dept of Anaesthesiology Moderator Dr. Ravinagaprasad Asst. prof Dept of Anaesthesiology Chair person Dr. Siddapa Gourav Prof Dept of Anaesthesiology. Speaker

Pre-operative risk factor assessment and minimizing the risk factors. Anesthetic management proper. Post operative jaundice.

Risk assessment for Anaesthesia in patients with Liver disease

Assessment of risk factors in moderate to severe liver disease CHILD-TURCOTT classification posted for major surgery
Gr-A Gr-B 2-3 Moderate Gr 1-2 Undernourished 2.8-3.5 30% Gr-C >3 Tense Gr 3-4 Poor <2.8 >40%

Factor

Sr.bilirubin(mg/dl <2 ) Ascites Encephalopathy Nutrition S. ALBUMIN(gm%) Risk(Mortality rate) NO NO Good >3.5 <10%

Child-pugh modification ( 1972 )

Factor Sr.bilirubin(mg/dl) Ascites Encephalopathy <2 NO NO 1 2-3 Moderate Gr 1-2 2 >3 Tense Gr 3-4 3

PT (Sec prolonged) INR S. ALBUMIN(gm%)

<4 <1.7 >3.5

4-6 1.7-2.3 2.8-3.5

>6 >2.3 <2.8

MELD Score Modified end stage liver disease

Sr.Bilirubin Sr.Albumin Sr.Creatinine

Meld commonly used for Transplantation and Shunt surgeries

Pre op variables and peri op mortality rate in cirrhotic patients (Garrison etal)

Risk factor Mortality rate Emergency surgery 57% S.albumin <3gm/dl 58% S.bilirubin> 3mg/dl 62% PT >1.5 X control 63% Infection 64% Antibiotics >2 82% Cardiac failure 92% Pulmonary failure 100% WBC count > 10,000 cells/cumm

Causes of mortality (perioperatively)

Sepsis Renal failure Bleeding Hepatic failure Encephalopathy Pulmonary failure

Anesthetic management of patients with moderate to severe liver disease includes Pre-op optimisation of condition Modifying and minimising the risk factors of mortality

Management of various risk factors

Ascites indicates severe liver disease Elective surgery: carbohydrate and protein diet restrict sodium intake 2gm/day Not responding to salt restriction Use of potassium sparing diuretics alone/ loop diuretics

Tab. spironolactone 100mg/day max 400mg/d Tab. Amiloride 5-10 mg/d Frusemide 40-160 mg/d if hyponatremia (<125meq/l) restrict fluid intake 800-1000ml/d Goal: Pre-op sodium level >130mmol/L Large volume paracentesis: tense ascites - wt.loss <0.5kg/d if >1lt/d supplement with salt free albumin 10gm/d , dextran -70 8gm/d, gelatin 125ml/d.

SBP is a common and severe complication of ascites characterized by spontaneous infection of the ascitic fluid without an intraabdominal source. most common organisms are Escherichia coli and other gut bacteria; however, gram-positive bacteria, including Streptococcus viridans, Staphococcus aureus, and Enterococcus sp diagnosis of SBP : absolute neutrophil count >250/mm3 Treatment :second-generation cephalosporin, inj. cefotaxime 2gm tid x 5d

Alternative treatment ceftriaxone + amoxycillin - clavulanic acid inj. Ciprofloxacin 200mg i.v b.d x 2d followed by tab. Ciprofloxacin 500mg b.d x 5d response to therapy dec. in PMN by 50% in 48hrs. prophylaxis: high risk cases tab. Norflox tab. Ciprofloxacin 500mg b.d x5d tab. Septran ds b.d x 5d/wk

Pulmonary function Hypoxemia PaO2 <70mmHg Decreased HPV response Treat associated pul. disease (smokerCOPD) Chest physiotherapy Pulmonary toileting Bronchodilators Antibiotics

Renal system:
Pre renal Azotemia- correct by fluid administration Renal failure- Gram ve septicemia, Endotoxin mediated, Bilirubin mediated Diuresis by mannitol Antibiotic coverage (non toxic)

Asses for Hepatorenal syndrome (mortality 95%) type I doubled s.creatinine (2.5mg/dl) halved creatinine clearance 20ml/min in 2wks. type II progressive , chronic, resistant to treatment

Rx: i.v infusion of albumin dopamine + long acting vassopressin ( ornipressin / terlipressin) octreotide midodrine, an alpha-agonist (under trail) TIPS The best therapy for HRS is liver transplantation Goal: Urine out put 50ml/hr

Bleeding and clotting abnormalities Decrease in Vit K dependent factors Decreased intrinsic factors Decreased t1/2 of clotting factors due to consumptive coagulopathy Qualitative and quantitative platelet defects, thrombocytopenia Goal: PT < 2.5 sec of control

Obstructive jaundice Elective surgery Vit K can be given preoperatively Dose: 5-10mg/day x 7 IM 5-10mg TID x 3 IM In emergency : 5-10mg 4th hourly

Coagulopathy : PT 2-3 sec control FFP 2-6 units need to be transfused 1FFP increases clotting factors by 20% 250ml FFP increases fibrinogen by 10% Platelets<40,000/ clinicallybleeding diathesis - Platelet transfusion required

Hepatic Encephalopathy:
Increased Ammonia conc., increased GABA activity

Preventive measures: hydration and correction of electrolyte imbalance correcting precipitating factors vegetable protein better than animal protein
use lactulose, a nonabsorbable disaccharide acute cases- 30 40ml tid x 7d, 2-3 soft stools/d no response add Poorly absorbed antibiotics neomycin 0.5 -1gm tid x 7d metronidazole 250mg tid x 7d rifaximin - 1200mg od

Specific BZD antagonist Flumazenil Others: sodium benzoate , LOLA.

Metabolic disturbances: Metabolic alkalosis Hypokalemia Hypocalcemia Hyperglycemia Hypoglycemia

General measures: Acceptable sr.Albumin >3gm/dl Acceptable Sr.Bilirubin (if >8mg/dl pre-op mannitol to be given) Anemia : iron deficiency anemia ferrous sulphate 300mg tid megaloblastic folic acid 1mg/d , vit. B12 packed cell transfusion if Hct< 28% Nutrition : calories 25- 30 kcal/kg/d protein 1-1.2gm/kg/d hepatic encephalopathy restrict to 60gm/d Other factors : stop alcohol, stop smoking, correct electrolyte imbalance

Type of Anesthesia

RA- If clotting profile is normal for surgeries on periphery Major intra-abdominal surgeries GA Monitoring: routine ASA monitoring spo2,ECG,NIBP,Etco2 Severe disease/major surgery Invasive: IBP, CVP Periodic ABG analysis RBS, Sr.electrolytes, Haematocrit PT,APTT, Thromboelastography

GA: Pre-med: no/minimal sedative Fentanyl (min dose) Metaclopromide (full stomach) Rapid sequence induction and intubation Induction: Propofol 2mg/kg (best agent) Thiopentone 3-5mg/kg (single dose) Intubation: Suxamethonium (duration slightly prolonged)

Maintanance : O2, N2O mixture NDMR- Atracurium/Cis-Atracurium (safe) large initial doses( inc. vd ) subsequent doses should be decreased Avoid injury/ insult to Liver Goal: maintain liver blood flow and O2 supply

Hypoxia, V/Q mismatch- increase Fio2 Prevent arterial hypotension, fall in cardiac out put Inhalational agent: Isoflurane best agent Sevoflurane Halothane better avoided in cases with liver disease. Fluid and blood products

Post-op Jaundice

Incidence in abdominal procedures <1% Manifestation: increased ALT/AST/S.bilirubin/clinical jaundice

1. 2. 3.

Only bilirubinemia:
Resorption of large haematoma, multiple blood transfusions Congenital: Gilberts, Rotors, Dubin-johnson (prognosis good), criggler-najjar syn. Intravascular haemolysis- haemolytic anaemia, G-6-PD deficiency, Sickle cell anaemia

Bilirubinemia with mild mod amino transferase increase:

post op intra hepatic cholestasis- mild fever , jaundice, upper abdominal pain <48hrs & recedes in 2-3wks Biliary tract obstruction: retained stones in biliary tract, duct injury, acute cholecystitis post op, acute pancreatitis. Circulatory failure: open heart surgery/traumatic circulatory shock, ischemic hepatic injury. Sepsis mainly obstructive type (high bilirubin levels)

Bilirubinemia with marked amino transferase increase: Shock liver- centrilobular necrosis due to hypoxia, viral hepatitis Drug induced hepatitis: alcohol AST:ALT >2:1 isoniazid,phenytoin,methyl dopa tetracycline, oc pills asprin, acetaminophin.

Halogenated inhalational agents: halothane hepatitis- type 1 type 2( severe form) Obesity: BMI >30 post op liver failure likely in 30% cases.

Time course of onset of post op jaundice

0-1wk : intra hepatic cholestasis resorption of hematoma hypotension- ischaemic hepatitis 1-2wks: above causes sepsis, biliary trauma, pancreatitis nonA,nonB hepatitis halothane hepatitis

Pre op proper history taking: h/o hepatitis(viral) familial disease,drug history, alcohol overuse, h/o jaundice past obesity, exposure to halothane Intra op: shock, retraction/major abdominal surgery, sepsis, biliary tract surgery.

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