LIVER

Q. 1) Systemic problems encountered in a patient with long standing cirrhosis

How would you evaluate the risk of surgery in such patients?
Ans a)
1) GIT portal HTN 3. Hepatorenal syndrome
1. Ascites 8)
2. Esophageal varices 9)
3. Hemorrhoids 10)
4. GI bleed 11)
2) 12) Hematological
3) Circulatory 1. Anemia
1. Hyper-dynamic state ( Cardiac 2. Coagulopathy
3. Hypersplenism
output)
4. Thrombocytopenia/ Leucopenia.
2. Systemic arteriovenous shunts
13)
3. Low SVR 14) Infections
4. Cirrhotic cardiomyopathy 1. Spontaneous bacterial
4) peritonitis.
5) Pulmonary: 15)
1. intrapulmonary shunting 16) Metabolic:
2. FRC Restrictive ventilator 1 Hyponatremia
defect 2. Hypokalemia
3. Pleural effusion WOB 3. Hypomagnesaemia
4. Respiratory alkalosis 4. Hypoalbuminemia
6) 5. Hypoglycemia
7) Renal: 17)
1. Na reabsorption. 18) Neurological:
2. Renal perfusion 1. Encephalopathy.

1
Dr. Tariq Mahar
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20) Ans B)
21) CHILDS CLASSIFICATION FOR EVALUATION (MODIFIED BY POGH)
22) Risk Group A B C
23) Bilirubin (mg/dl) <2.0 2.0-3.0 >3.0
24) Albumen g/dl >3.5 3.0-3.5 <3.0
25) Ascites None Controlled poorly
26) Controlled
27) Encephalopathy Absent Minimum Coma
28) Mortality rate (%) 2-5% 10% 50%
29) PT sec <18 18-20 >20
30) INR <1.7 1.7-2.3 >2.3
31) Nutrition Excellent Good Poor
32) CIRRHOSIS
33) Q.) What are the anesthetic considerations in a patient with cirrhosis
scheduled for major abdominal surgery?

34) Ans)
35) PREOP CONSIDERATIONS:
1. History (Duration of Dx, severity, ascites, medications, nutrition)
2. Functional class.
3. Comorbidities
4. Previous anesthetics
5. Drug history
6. Allergy
7. Smoking and alcohol
8. Neurological status
9. General physical examination.
10.Airway assessment.
11.Volume status.
36) Hepatic dysfx and perioperative risk.
37) So evaluate by childs classification.
12.Investigations
1. FBC
2. UCEs
3. Clotting screen
4. Glucose
5. LFTs
6. ABGs
7. CXR
8. Urine DR.
9. Serum albumin
10.Serum ammonia
11.Hepatitis screening LRCP, CT, MRI and cholangiogram.
12.ERCP
13.Special preoperative consideration:
 1) Arrange FFP, Platelets, cryoprecipitate and PRBC.
2) Correction of anemia PRBCs
3) If pulmonary function compromise (large ascites) paracentesis of ascetic
fluid
4) Correction of coagulopathy FFP, Platelets and cryoprecipitate
5) Correction of encephalopathy Oral lactulose or neomycin
14. Premedications:
38) Aspiration prophylaxis (ascites)
39) Lorazepam and thiamins alcoholic pts with withdrawal
40) INTRAOP CONSIDERATIONS:
41) GOAL: To preserve existing hepatic function and prevents any further
deterioration in liver function.
1. Universal precautions are indicated in preventing contact with blood and
body fluid if patients are carriers of hepatitis B and C virus.
2. Pre-oxygenation and RSI with cricoid pressure, using Propofol or etomidate
and low dose suxa most common
3. For unstable patient and those with active bleeding an awake intubation or
RSI with cricoid pressure using ketamine and suxa are best advised.
4. Requires larger than (n) loading dose and smaller than (n) maintenance dose
of NMBA needed (Pancuronium, Rocuronium, Vecuronium)
5. Cisatracurium-NMBA of choice unique non-hepatic metabolism
6. Halothane is best avoided (LFT deteriorate postoperatively) Isoflurane 1 st
choice.
7. Remifentanil and fentanyl are good opioid choice.
8. Na+ restricted patients so use colloid IV fluids (albumin) OP
9. Avoid profound hypotension and renal shutdown colloid IV fluids as ascitic
patient and prolong procedure large fluid shift
10.Avoid unnecessary transfusion significant transfusioncitrate toxicity
treated by IV calcium.
11.Monitor persistent UO despite adequate fluid replacement.
12.Special monitoring includes: ECG, Pulse Oximetry, ETCO 2 , arterial line, CVP,
PAC, temperature, ABGs and Urine Output
13.Postop pain acetaminophen.
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