UpToDate
Official reprint from UpToDate®
www.uptodate.com ©2017 UpToDate, Inc. and/or its affiliates. All Rights Reserved.

Anesthesia for the patient with liver disease

Authors
Randolph H Steadman, MD, MS
Victor W Xia, MD
Section Editor
Stephanie B Jones, MD
Deputy Editor
Marianna Crowley, MD

INTRODUCTION

Patients with liver disease frequently require surgery and anesthesia, and are at increased risk of intraoperative complications and postoperative morbidity and mortality. This topic will discuss anesthetic management of patients with liver disease.

Epidemiology, diagnosis and management of various forms of liver disease, and preoperative risk assessment for patients with liver disease, are discussed separately. (See "Assessing surgical risk in patients with liver disease".)

PREOPERATIVE EVALUATION AND OPTIMIZATION

Screening for liver disease — The preoperative history and physical examination for any patient should include the risk factors, signs, and symptoms of liver disease. Routine screening with liver function tests (LFTs) is not recommended, due to its low yield and uncertain implications for patients with no known liver disease. (See "Assessing surgical risk in patients with liver disease", section on 'Screening for liver disease before surgery'.)

Preoperative evaluation for patients with known liver disease — Prior to surgery, the etiology, duration, and severity of hepatic dysfunction should be determined. Risk stratification and optimization of medical status should be performed preoperatively for elective surgery.

Risk stratification — A number of conditions are considered contraindications to elective surgery (table 1), including acute liver failure (previously termed fulminant hepatic failure) and acute viral or alcoholic hepatitis. Patients with mild to moderate chronic liver disease without cirrhosis usually tolerate surgery well. (See "Assessing surgical risk in patients with liver disease", section on 'Obstructive jaundice'.)

                             
To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:

Subscribers log in here

Literature review current through: Sep 2017. | This topic last updated: Jul 18, 2017.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2017 UpToDate, Inc.
References
Top
  1. Northup PG, Wanamaker RC, Lee VD, et al. Model for End-Stage Liver Disease (MELD) predicts nontransplant surgical mortality in patients with cirrhosis. Ann Surg 2005; 242:244.
  2. Teh SH, Nagorney DM, Stevens SR, et al. Risk factors for mortality after surgery in patients with cirrhosis. Gastroenterology 2007; 132:1261.
  3. Suman A, Barnes DS, Zein NN, et al. Predicting outcome after cardiac surgery in patients with cirrhosis: a comparison of Child-Pugh and MELD scores. Clin Gastroenterol Hepatol 2004; 2:719.
  4. Farnsworth N, Fagan SP, Berger DH, Awad SS. Child-Turcotte-Pugh versus MELD score as a predictor of outcome after elective and emergent surgery in cirrhotic patients. Am J Surg 2004; 188:580.
  5. Perkins L, Jeffries M, Patel T. Utility of preoperative scores for predicting morbidity after cholecystectomy in patients with cirrhosis. Clin Gastroenterol Hepatol 2004; 2:1123.
  6. Befeler AS, Palmer DE, Hoffman M, et al. The safety of intra-abdominal surgery in patients with cirrhosis: model for end-stage liver disease score is superior to Child-Turcotte-Pugh classification in predicting outcome. Arch Surg 2005; 140:650.
  7. Zardi EM, Abbate A, Zardi DM, et al. Cirrhotic cardiomyopathy. J Am Coll Cardiol 2010; 56:539.
  8. Theocharidou E, Krag A, Bendtsen F, et al. Cardiac dysfunction in cirrhosis - does adrenal function play a role? A hypothesis. Liver Int 2012; 32:1327.
  9. Alkhouri N, Tamimi TA, Yerian L, et al. The inflamed liver and atherosclerosis: a link between histologic severity of nonalcoholic fatty liver disease and increased cardiovascular risk. Dig Dis Sci 2010; 55:2644.
  10. Butt AA, Xiaoqiang W, Budoff M, et al. Hepatitis C virus infection and the risk of coronary disease. Clin Infect Dis 2009; 49:225.
  11. Petta S, Maida M, Macaluso FS, et al. Hepatitis C Virus Infection Is Associated With Increased Cardiovascular Mortality: A Meta-Analysis of Observational Studies. Gastroenterology 2016; 150:145.
  12. Marik PE, Baram M, Vahid B. Does central venous pressure predict fluid responsiveness? A systematic review of the literature and the tale of seven mares. Chest 2008; 134:172.
  13. Niemann CU, Feiner J, Behrends M, et al. Central venous pressure monitoring during living right donor hepatectomy. Liver Transpl 2007; 13:266.
  14. Myo Bui CC, Worapot A, Xia W, et al. Gastroesophageal and hemorrhagic complications associated with intraoperative transesophageal echocardiography in patients with model for end-stage liver disease score 25 or higher. J Cardiothorac Vasc Anesth 2015; 29:594.
  15. Markin NW, Sharma A, Grant W, Shillcutt SK. The safety of transesophageal echocardiography in patients undergoing orthotopic liver transplantation. J Cardiothorac Vasc Anesth 2015; 29:588.
  16. Spier BJ, Larue SJ, Teelin TC, et al. Review of complications in a series of patients with known gastro-esophageal varices undergoing transesophageal echocardiography. J Am Soc Echocardiogr 2009; 22:396.
  17. Kennedy WF Jr, Everett GB, Cobb LA, Allen GD. Simultaneous systemic and hepatic hemodynamic measurements during high peridural anesthesia in normal man. Anesth Analg 1971; 50:1069.
  18. Meierhenrich R, Wagner F, Schütz W, et al. The effects of thoracic epidural anesthesia on hepatic blood flow in patients under general anesthesia. Anesth Analg 2009; 108:1331.
  19. Tanaka N, Nagata N, Hamakawa T, Takasaki M. The effect of dopamine on hepatic blood flow in patients undergoing epidural anesthesia. Anesth Analg 1997; 85:286.
  20. McDonnell JG, O'Donnell B, Curley G, et al. The analgesic efficacy of transversus abdominis plane block after abdominal surgery: a prospective randomized controlled trial. Anesth Analg 2007; 104:193.
  21. Frink EJ Jr. The hepatic effects of sevoflurane. Anesth Analg 1995; 81:S46.
  22. Schindler E, Müller M, Zickmann B, et al. [Blood supply to the liver in the human after 1 MAC desflurane in comparison with isoflurane and halothane]. Anasthesiol Intensivmed Notfallmed Schmerzther 1996; 31:344.
  23. Gelman S, Dillard E, Bradley EL Jr. Hepatic circulation during surgical stress and anesthesia with halothane, isoflurane, or fentanyl. Anesth Analg 1987; 66:936.
  24. Njoku D, Laster MJ, Gong DH, et al. Biotransformation of halothane, enflurane, isoflurane, and desflurane to trifluoroacetylated liver proteins: association between protein acylation and hepatic injury. Anesth Analg 1997; 84:173.
  25. Obata R, Bito H, Ohmura M, et al. The effects of prolonged low-flow sevoflurane anesthesia on renal and hepatic function. Anesth Analg 2000; 91:1262.
  26. Watkins PB, Seeff LB. Drug-induced liver injury: summary of a single topic clinical research conference. Hepatology 2006; 43:618.
  27. Nunn JF. Clinical aspects of the interaction between nitrous oxide and vitamin B12. Br J Anaesth 1987; 59:3.
  28. Sesso RM, Iunes Y, Melo AC. Myeloneuropathy following nitrous oxide anesthaesia in a patient with macrocytic anaemia. Neuroradiology 1999; 41:588.
  29. Hadzic A, Glab K, Sanborn KV, Thys DM. Severe neurologic deficit after nitrous oxide anesthesia. Anesthesiology 1995; 83:863.
  30. Servin F, Desmonts JM, Haberer JP, et al. Pharmacokinetics and protein binding of propofol in patients with cirrhosis. Anesthesiology 1988; 69:887.
  31. Duvaldestin P, Chauvin M, Lebrault C, et al. Effect of upper abdominal surgery and cirrhosis upon the pharmacokinetics of methohexital. Acta Anaesthesiol Scand 1991; 35:159.
  32. Pandele G, Chaux F, Salvadori C, et al. Thiopental pharmacokinetics in patients with cirrhosis. Anesthesiology 1983; 59:123.
  33. van Beem H, Manger FW, van Boxtel C, van Bentem N. Etomidate anaesthesia in patients with cirrhosis of the liver: pharmacokinetic data. Anaesthesia 1983; 38 Suppl:61.
  34. Riker RR, Shehabi Y, Bokesch PM, et al. Dexmedetomidine vs midazolam for sedation of critically ill patients: a randomized trial. JAMA 2009; 301:489.
  35. Tegeder I, Lötsch J, Geisslinger G. Pharmacokinetics of opioids in liver disease. Clin Pharmacokinet 1999; 37:17.
  36. Klotz U, McHorse TS, Wilkinson GR, Schenker S. The effect of cirrhosis on the disposition and elimination of meperidine in man. Clin Pharmacol Ther 1974; 16:667.
  37. Pond SM, Tong T, Benowitz NL, et al. Presystemic metabolism of meperidine to normeperidine in normal and cirrhotic subjects. Clin Pharmacol Ther 1981; 30:183.
  38. Dershwitz M, Hoke JF, Rosow CE, et al. Pharmacokinetics and pharmacodynamics of remifentanil in volunteer subjects with severe liver disease. Anesthesiology 1996; 84:812.
  39. Navapurkar VU, Archer S, Gupta SK, et al. Metabolism of remifentanil during liver transplantation. Br J Anaesth 1998; 81:881.
  40. Thomas SD, Boyd AH. Prolonged neuromuscular block associated with acute fatty liver of pregnancy and reduced plasma cholinesterase. Eur J Anaesthesiol 1994; 11:245.
  41. Viby-Mogensen J, Hanel HK. Prolonged apnoea after suxamethonium: an analysis of the first 225 cases reported to the Danish Cholinesterase Research Unit. Acta Anaesthesiol Scand 1978; 22:371.
  42. Cook DR, Freeman JA, Lai AA, et al. Pharmacokinetics of mivacurium in normal patients and in those with hepatic or renal failure. Br J Anaesth 1992; 69:580.
  43. Devlin JC, Head-Rapson AG, Parker CJ, Hunter JM. Pharmacodynamics of mivacurium chloride in patients with hepatic cirrhosis. Br J Anaesth 1993; 71:227.
  44. Hunter JM, Parker CJ, Bell CF, et al. The use of different doses of vecuronium in patients with liver dysfunction. Br J Anaesth 1985; 57:758.
  45. Magorian T, Wood P, Caldwell J, et al. The pharmacokinetics and neuromuscular effects of rocuronium bromide in patients with liver disease. Anesth Analg 1995; 80:754.
  46. De Wolf AM, Freeman JA, Scott VL, et al. Pharmacokinetics and pharmacodynamics of cisatracurium in patients with end-stage liver disease undergoing liver transplantation. Br J Anaesth 1996; 76:624.
  47. Ward S, Neill EA. Pharmacokinetics of atracurium in acute hepatic failure (with acute renal failure). Br J Anaesth 1983; 55:1169.
  48. Møller S, Henriksen JH. Neurohumoral fluid regulation in chronic liver disease. Scand J Clin Lab Invest 1998; 58:361.
  49. Wagener G, Kovalevskaya G, Minhaz M, et al. Vasopressin deficiency and vasodilatory state in end-stage liver disease. J Cardiothorac Vasc Anesth 2011; 25:665.
  50. Alves de Mattos A. Current indications for the use of albumin in the treatment of cirrhosis. Ann Hepatol 2011; 10 Suppl 1:S15.
  51. Bernardi M, Ricci CS, Zaccherini G. Role of human albumin in the management of complications of liver cirrhosis. J Clin Exp Hepatol 2014; 4:302.
  52. Runyon BA, AASLD Practice Guidelines Committee. Management of adult patients with ascites due to cirrhosis: an update. Hepatology 2009; 49:2087.
  53. Terg R, Gadano A, Cartier M, et al. Serum creatinine and bilirubin predict renal failure and mortality in patients with spontaneous bacterial peritonitis: a retrospective study. Liver Int 2009; 29:415.
  54. Ganter MT, Spahn DR. Active, personalized, and balanced coagulation management saves lives in patients with massive bleeding. Anesthesiology 2010; 113:1016.
  55. Kozek-Langenecker SA, Ahmed AB, Afshari A, et al. Management of severe perioperative bleeding: guidelines from the European Society of Anaesthesiology: First update 2016. Eur J Anaesthesiol 2017; 34:332.
  56. Rossaint R, Bouillon B, Cerny V, et al. The European guideline on management of major bleeding and coagulopathy following trauma: fourth edition. Crit Care 2016; 20:100.
  57. Nadim MK, Durand F, Kellum JA, et al. Management of the critically ill patient with cirrhosis: A multidisciplinary perspective. J Hepatol 2016; 64:717.
  58. Spahn DR, Bouillon B, Cerny V, et al. Management of bleeding and coagulopathy following major trauma: an updated European guideline. Crit Care 2013; 17:R76.
  59. Tripodi A, Primignani M, Chantarangkul V, et al. Thrombin generation in patients with cirrhosis: the role of platelets. Hepatology 2006; 44:440.
  60. Senousy BE, Draganov PV. Evaluation and management of patients with refractory ascites. World J Gastroenterol 2009; 15:67.
  61. Evans C, Evans M, Pollock AV. The incidence and causes of postoperative jaundice. A prospective study. Br J Anaesth 1974; 46:520.
  62. Suttner SW, Schmidt CC, Boldt J, et al. Low-flow desflurane and sevoflurane anesthesia minimally affect hepatic integrity and function in elderly patients. Anesth Analg 2000; 91:206.
  63. Lentschener C, Benhamou D, Mercier FJ, et al. Aprotinin reduces blood loss in patients undergoing elective liver resection. Anesth Analg 1997; 84:875.
  64. Jones RM, Moulton CE, Hardy KJ. Central venous pressure and its effect on blood loss during liver resection. Br J Surg 1998; 85:1058.
  65. The administration of blood and blood components and the management of transfused patients. British Committee for Standards in Haematology, Blood Transfusion Task Force. Royal College of Nursing and the Royal College of Surgeons of England. Transfus Med 1999; 9:227.
  66. Kim YK, Chin JH, Kang SJ, et al. Association between central venous pressure and blood loss during hepatic resection in 984 living donors. Acta Anaesthesiol Scand 2009; 53:601.
  67. Chhibber A, Dziak J, Kolano J, et al. Anesthesia care for adult live donor hepatectomy: our experiences with 100 cases. Liver Transpl 2007; 13:537.
  68. Li Z, Sun YM, Wu FX, et al. Controlled low central venous pressure reduces blood loss and transfusion requirements in hepatectomy. World J Gastroenterol 2014; 20:303.
  69. Hughes MJ, Ventham NT, Harrison EM, Wigmore SJ. Central venous pressure and liver resection: a systematic review and meta-analysis. HPB (Oxford) 2015; 17:863.
  70. Sand L, Rizell M, Houltz E, et al. Effect of patient position and PEEP on hepatic, portal and central venous pressures during liver resection. Acta Anaesthesiol Scand 2011; 55:1106.
  71. Torzilli G, Procopio F, Donadon M, et al. Safety of intermittent Pringle maneuver cumulative time exceeding 120 minutes in liver resection: a further step in favor of the "radical but conservative" policy. Ann Surg 2012; 255:270.
  72. Bismuth H, Castaing D, Garden OJ. Major hepatic resection under total vascular exclusion. Ann Surg 1989; 210:13.
  73. Matot I, Scheinin O, Eid A, Jurim O. Epidural anesthesia and analgesia in liver resection. Anesth Analg 2002; 95:1179.
  74. Borromeo CJ, Stix MS, Lally A, Pomfret EA. Epidural catheter and increased prothrombin time after right lobe hepatectomy for living donor transplantation. Anesth Analg 2000; 91:1139.