Anesthetic Considerations in Patients With Hepatic Failure

Perioperative management of liver surgery-review on pathophysiology of liver disease and liver failure

An increasing number of patients present for liver surgery. Given the complex pathophysiological changes in chronic liver disease (CLD), it is pivotal to understand the fundamentals of chronic and acute liver failure. This review will give an overview on related organ dysfunction as well as recommendations for perioperative management and treatment of liver failure-related symptoms.

Anesthetic considerations for the patient with liver disease

PURPOSE OF REVIEW

An increasing number of patients requiring surgery are presenting with chronic or end stage liver disease. The management of these patients demands anesthesiologists with in-depth knowledge of the consequences of hepatic dysfunction, the effects on other organs, the risk of surgery, and the impact of anesthesia.

RECENT FINDINGS

Chronic or end stage liver disease is associated with an increased risk of perioperative morbidity and mortality. It is essential to preoperatively assess possible hepatic encephalopathy, pleural effusions, hepatopulmonary syndrome, hepatopulmonary hypertension, hepatorenal syndrome, cirrhotic cardiomyopathy, and coagulation disorders. The application of two scoring systems, that is, Child-Turcotte-Pugh and model for end stage liver disease, helps to estimate the risk of surgery. The use of propofol is superior to benzodiazepines as intravenous narcotics. Although enflurane and halothane are discouraged for maintenance of anesthesia, all modern volatile anesthetics appear comparable with respect to outcome. Fentanyl, sufentanil, and remifentanil as opioids and cis-atracurium for relaxation may be the best choices in liver insufficency. Regional anesthesia is valuable for postoperative pain management.

SUMMARY

Current studies have employed different anesthetic approaches in the preoperative and intraoperative management in order to improve outcomes of patients with liver disease.

Palliation and liver failure: palliative medications dosage guidelines

Palliation of symptoms is important in a variety of conditions, both malignant and nonmalignant. These symptoms may be present in patients with chronic or acute liver failure. However, to date there is a notable lack of reliable information on the use of medications that are commonly required in the palliative care of these patients. To facilitate care, a literature review was conducted with extensive searches of MEDLINE and Micromedex as well as reviews of the major textbooks of pharmacology, palliative care, gastroenterology and hepatology. A table is presented that includes medications organized in groupings of functional importance in palliative medicine such as opioids, antiarrhythmics, antidepressants, aperients, and other medications as selected for use at a Sydney palliative care unit. Data have been collected on the pharmacologic half-life in normal liver function and in cirrhosis. The latter, where suitable data could be obtained, were divided into three subgroups, using the Child-Pugh criteria. The further development of this information may help limit difficulties in choice of medication and reduce potential complications and improve palliation.

Monitoring Hepatic and Renal Function

Liver disease represents a serious risk factor for patients requiring anesthesia and surgery. Even subclinical liver disease increases perioperative morbidity and mortality. Perioperative renal dysfunction and failure have similar implications. Thus, detection of early hepatic and renal dysfunction and monitoring of their progress is essential. This article discusses methods for monitoring hepatic and renal function in patients who have high risk for liver or renal injury in the perioperative period.