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Anaesthetic Management In A

Patient With Liver Disease


Pre-Anesthetic Checkup (PAC)

-See extent of liver disease and effect on other


systems—CHF,Resp.failure,Pul.embolism,renal insuff.
- Look for:-
• Muscle wasting
• Spider Navi
• Pleural infusion
• Ascitis
• Splenomegaly
-ASA risk identification with Child Pugh's Classification
PARAMETER MILD MODERATE SEVERE
S.ALBUMIN(g/dl) <3.5 3-3.5 <3
S. BILIRUBIN(mg/DL) <2 2-3 >3
PT (sec. prolonged) 1-4 4-6 <6
ASCITIS NO MOD. SEVERE
ENCEPHALOPATHY NO MOD. SEVERE

NUTRITION EXCELLENT GOOD POOR


Investigations

• CBC--1.Anemia
2.Thrombocytopenia
3. TLC Indicating Infections
• Liver func. Test-1.PT-diagnostic and prognostic indicator.
2.S.Bilirubin, S.Albumin,SGOT,SGPT

• Renal function test-NA+K+


• ECG, ECHO-to check LV Dys., CAD
• CXR-to check pleural effusion.
Management of Anaesthesia
If emergency surgery –urgent optimisation of patient
1.LOOK FOR IV STATUS
2.COAGULATION STATUS
3.CNS ASSESMENT
4.INFECTION
If PT<1.5 -------Give FFP
TPC<50,000------Give Platelets
Fibrinogen<1gm/dL--------Cryoppt.
• if risk of periop. bleeding use --recombinant factor VIIA
--Desmopression
--TX
Choice of anesthesia

• Regional anaesthesia-spinal/epidural/blocks- can be


given if coagulation status normal.

• General anaesthesia-1.maintain hepatic blood flow


and oxygenation.
2.avoiding hepatoxic drugs.
Premedication

• H2 Antagonist to decrease risk of Aspiration.

• Avoid sedation as it increases encephalopathy.

• Analgesic-Remifentanyl is ideal.
-Fentanyl is low doses.
-Avoid Morphine, Alfentanyl.
Intra-Operative Management
• Decreased doses of thiopental, propofol.

• Etomidate is slightly better choice.

• Rapid sequence induction with cricoid pressure.


• scoline action may prolong due to decrease plasma cholinesterase level.

• Decreased dose of NDMR relaxants initially.


• Atra/Cisatra best suitable, vecuronium up to 0.1mg/kg.

• Volatile anesthetic- iso-, sevo-, desflurane are safe--least metabolism, quick emergence
preserve hepatic blood flow.

• Fluid replacement— Colloids better then crystalloids


-5-10% Dextrose @ 50-100ml/hr for hypoglycemia.
-BT as slow as possible as decreased clearance of citrate by cirrhotic liver.
-Monitor urine output, CVP.
Post operative care
• Avoid sedation to check CNS function and
encephalopathy status.
• Moniter P.O bleeding, coagulopathy status, LFT ,
sepsis, jaundice, poor wound healing.
• Fluid m/m , BP monitoring to avoid PO renal failure.
Post operative pain M/M
• Tap block, local infilteration, epidural- if coagulation
normal
• PCA via remifentanyl.
• Avoid IM/S.C Inj.- R/O Hematoma.
• Avoid NSAIDS -- risk of GIT bleeding, platelet
dysfunc., Nephrotoxicity.
• Use Actaminophen with LFT monitoring.
Causes of liver diseases

• Alcoholic disease
• Hepatitis (B and C)
• Drugs
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