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Liver disease

Created: 4/2/2005

 
A high-risk group for anaesthesia

Classification system to assess risk:

  • Ascites
  • Encephalopathy
  • Bilirubin
  • Albumin
  • Prothrombin time

Pharmacokinetics

Distribution:

  • Decreased albumin levels – decreased protein binding and therefore increased free drug e.g. thiopentone
  • Unbound portion is able to distribute widely; therefore the Vd increases

Detoxification: decreased hepatic clearance of drugs (benzodiazepines and opioids)

Elimination: decreased biliary excretion

Other problems

  • Ascites: fall in functional reserve capacity
  • Coagulopathy: decreased production of vitamin K-dependent clotting factors (II,VII,IX,X) and non-vitamin K-dependent clotting factors (V,XI,XII,XIII) and altered platelet function
  • Renal: hepatorenal syndrome and acute tubular necrosis. Increased plasma volume
  • Cardiovascular: high cardiac output and low systemic vascular resistance (severe)
  • RS:V/Q mismatch reduces PaO2

Metabolic: hypoglycaemia and sodium retention

Neurology: encephalopathy

Drugs: corticosteroids

Assessment

  • Optimise condition by hepatologist
  • May take several weeks (esp. nutrition)
  • Full blood count, urea & electrolytes, clotting, liver function tests, glucose, arterial blood gases
  • ECG, chest X-ray and hepatitis B status
  • Vitamin K and mannitol may be needed preoperatively

Conduct

  • Monitoring: Central venous pressure, arterial, capnography, urine output, temperature, nerve stimulator, pulmonary artery wedge pressure if severe myocardial abnormalities
  • Regional?? Best option
  • General; lower doses required: increased volume of distribution
  • Careful titration
  • Atracurium thiopentone and isoflurane
  • Increased FiO2 and careful fluid balance
  • Perioperative mannitol to maintain urine output
  • Avoid lactate and Na fluids, give 5% dextrose
  • Warm

Postoperatively

  • ITU may be required
  • Accurate fluid balance
  • Analgesia, carefully
  • Risk of infection: prophylactic antibiotics

ArticleDate:20050204
SiteSection: Article
 
   
    
                                            
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