Anaesthetic considerations and peri-operative risks in patients with liver disease

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1 Anaesthetic considerations and peri-operative risks in patients with liver disease Dr. C. K. Pandey Professor & Head Department of Anaesthesiology & Critical Care Medicine Institute of Liver and Biliary Sciences, New Delhi

2 Objectives Recognize which coexisting disease processes are associated with increased morbidity Understand which features of the patient s condition can be improved Realize that a simple operation does not always mean an equally simple or risk-free anaesthetic

3 Natural progression of chronic liver disease Chronic liver disease Compensated cirrhosis Decompensated cirrhosis Death

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6 Risk scoring systems The risks are assessed in all surgical patients with liver disease: Child-Turcotte-Pugh Model for End-Stage Liver Disease (MELD) Scoring system Na + MELD

7 The Child-Turcotte-Pugh scoring system The risk of postoperative mortality and morbidity correlate well with the categorization of the patient as per the Child-Turcotte-Pugh (CTP) class of cirrhosis Scoring System assigns 1 to 3 points on the basis of five simple factors Sr. bilirubin Sr. albumin prothrombin time Ascites grade of encephalopathy

8 Risk scoring systems Variables Points Encephalopathy None 1 & 2 3 & 4 grade Ascites Absent Controlled Refractory Bilirubin mg/dl >2.0 Albumin gm/dl < 2.0 PT >6 Points Class One year survival Two year survival 5-6 A 100% 85% 7-9 B 81% 57% C 45% 35%

9 Model for end-stage liver disease (MELD) Scoring system The MELD scoring system was developed to prioritize eligibility for liver transplantation The MELD score is considered more objective and reliable because it is based on objective criteria i.e. serum bilirubin, serum creatinine and international normalized ratio (INR)

10 Model for end-stage liver disease MELD = 3.78 log e (bilirubin in mg/dl) log e (INR) log e (creatinine in mg/dl) (a bilirubin or creatinine value of less than 1.0 mg/dl is rounded to 1.0 mg/dl and the maximum creatinine value allowed is 4.0 mg/dl )

11 Strengths of the MELD score An objective metric using a continuous scale that lends itself to ranking patients based on disease severity It incorporates laboratory parameters that are easily available and reproducible Its validity as a robust mathematical model to assess mortality risk in patients with end-stage liver disease Superior to clinical judgment in identifying patients at risk of mortality

12 Evaluation MELD uses the patient's values for serum Bilirubin, serum Creatinine and the INR to predict survival. In interpreting the MELD Score in hospitalized patients, the 3 month mortality is: 40 or > <9 71.3% mortality 52.6% mortality 19.6% mortality 6.0% mortality 1.9% mortality

13 Open abdominal surgery MELD<10 :Survival rate 99% at 7 days 96% at 30 days 92% at 90 days CTP 5-6 :10% Mortality CTP 7-9 :30% Mortality MELD> 10 :Survival rates significantly lower CTP>9 :70 % Mortality Suman A.CleveJ Med 2006;73:

14 The relation between risk of 90-day mortality and individual MELD variables after adjustment for the other components. Gish RG. Liver Transpl 2007.

15 Na + MELD Serum sodium concentration - an important prognostic factor in patients with cirrhosis Addition of serum sodium into the MELD score predicts waiting list mortality better than MELD alone Serum sodium predicts mortality in patients listed for liver transplantation Hyponatremia is associated with neurologic dysfunction, refractory ascites, hepatorenal syndrome, and death from liver disease

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19 Peri-operative risks Surgery in acute liver disease Nature of Surgery Type of surgery Anaesthetic factors

20 Surgery in acute liver disease

21 Surgery in acute liver disease Acute liver diseases have higher operative risk Acute viral and alcoholic hepatitis has poor outcomes in surgical patients Major elective surgery for a patient with suspected acute hepatitis should be deferred until the patient has recovered Patients with acute hepatitis of any cause are regarded as having increased risk

22 Surgery in alcoholic hepatitis Alcoholic hepatitis is a contraindication to elective surgery and increases perioperative mortality Laparotomy in patient with alcoholic hepatitis may have serious consequences The mortality rate was 58% among the 12 patients who underwent open liver biopsy, compared with 10% among the 39 patients who underwent percutaneous liver biopsy Abstinence from alcohol for 12 weeks resulted in dramatic improvement in hepatic inflammation and hyperbilirubinemia Greenwood SM, Leffler CT, Minkowitz S. The increased mortality rate of open liver biopsy in alcoholic hepatitis. Surg Gynecol Obstet 1972;134:600-4

23 Patients with acute liver are critically ill and all surgery other than liver transplantation is contraindicated

24 Nature of surgery

25 Emergency surgery 138 patients with cirrhosis undergoing non hepatic general surgical procedure 120% 100% 80% 51% 60% 40% 20% 8.70% 49% 47% Elective Emergency 0% Patients Mortality Neeff H et al J Gastrointest Surg 2011 High risk :Emergency surgery

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27 TYPE OF SURGERY

28 Only MELD score, American Society of Anesthesiologists class, and age predicted mortality at 30 and 90 days, 1 year, and long-term independent of type of surgery

29 Type of surgery

30 Open abdominal surgery Fifty-three adult patients with cirrhosis undergoing abdominal surgery Patients undergoing hepatic surgery (resection or transplantation) or closed abdominal surgery (hernia repair) were excluded Total 13 patients (25%) had poor outcomes including 9 deaths (17%) Befeler AS, Palmer DE, Hoffman M, Longo W, Solomon H, Di Bisceglie AM. The safety of intra-abdominal surgery in patients with cirrhosis. Arch Surg 2005;140:

31 Open abdominal surgery Model for end-stage liver disease score and plasma hemoglobin levels lower than10 g/dl found to be independent predictors of poor outcomes A MELD score of 14 or greater was a better clinical predictor of poor outcome than CTP C Befeler AS, Palmer DE, Hoffman M, Longo W, Solomon H, Di Bisceglie AM. The safety of intra-abdominal surgery in patients with cirrhosis. Arch Surg 2005;140:

32 Open abdominal surgery The mortality rate was higher in patients with one or more of the followings: elevated bilirubin prolonged prothrombin time ascites decreased albumin encephalopathy portal hypertension emergent surgery Befeler AS, Palmer DE, Hoffman M, Longo W, Solomon H, Di Bisceglie AM. The safety of intra-abdominal surgery in patients with cirrhosis. Arch Surg 2005;140:

33 Obstructive jaundice Retrospective analysis 373 patients - risk factors for perioperative death were Hematocrit< 30% Sr Bilirubin >11 mg/dl Malignant cause of biliary obstruction Mortality 60 % if all 3 present 5% if none present If Benign Condition, preoperative optimization with ERCP Stenting External PTBD with radiology guidance Madical M/M - Ursodeoxycholic acid, lactulose

34 Cardiac surgery Safe in CTP A and selected CTP B Best cut of values for predicting mortality and hepatic decompensation CTP >7 & MELD >13 Clin Gastroenterol Hepatol 2004;2:

35 Laparoscopic cholecystectomy Laparoscopic cholecystectomy carries a low mortality rate. In a retrospective analysis of 226 patients with cirrhosis (Child-Pugh class A or B) who underwent laparoscopic cholecystectomy, only two died (0.88%) The reported mortality is low, but this figure is still significantly higher than in non-cirrhotic controls (0.01%) Yeh CN, Chen MF, Jan YY. Laparoscopic cholecystectomy in 226 cirrhotic patients. Experience of a single center in Taiwan. Surg Endosc 2002;16:

36 Laparoscopic cholecystectomy This suggest cutoff mark of MELD 8 for clearing patients with cirrhosis for laparoscopic cholecystectomy

37 Laparoscopic cholecystectomy Patients with cirrhosis undergone laparoscopic cholecystectomy, 2 out of the 33 (6%) patients with cirrhosis died at 90 days, compared with no mortality in 31 matched controls The rate of morbidity was 33% vs. 17% in the study Perkins L, Jeffries M, Patel T. Utility of preoperative scores for predicting morbidity after cholecystectomy in patients with cirrhosis. Clin Gastroenterol Hepatol 2004;2:

38 Asymptomatic gallstone disease? Patients with cirrhosis who have incidental GSD on ultrasonography should not undergo cholecystectomy unless the gallstones are symptomatic Because chances of liver function to deteriorate after surgery

39 Cholecystectomy: open or laparoscopic Retrospectively analysis 50 patients who had undergone cholecystectomy for symptomatic gallstone disease The procedure was open in half of the patients and laparoscopic in the other half All patients had Child-Pugh class A or B cirrhosis. Poggio JL, Rowland CM, Gores GJ, Nagorney DM, Donohue JH. A comparison of laparoscopic and open cholecystectomy in patients with compensated cirrhosis and asymptomatic gallstone disease. Surgery 2000;127:

40 Cholecystectomy: open or laparoscopic The study concluded that laparoscopic cholecystectomy is associated with statistically significant reductions in operating room time, blood loss, and length of hospital stay There was no deaths in either group Laparoscopic cholecystectomy should be recommended for patients with liver disease without decompensation

41 Mortality rates in patients undergone cholecystectomy with or without cirrhosis Variables Patients with normal liver function Patients with cirrhosis (P T < 2.5 second than control) Patient with cirrhosis PT > 2.5 seconds than control Mortality 1% 9% 83% Aranha GV, Sontag SJ, Greenlee HB. Cholecystectomy in cirrhotic patients: a formidable operation. Am J Surg 1982;143:55-60.

42 Preoperative variables and mortality rates of survivors and non-survivors of abdominal surgery Preoperative variables % of mortality if factors present % of mortality if factors absent Child Class A 10 B 31 C 76 Ascites Emergency Surgery Bilirubin > 3 mg/dl Albumin < 3gm/dl Prothrombin time > 1.5second above control WBC count > P < 0.01 for all variables

43 Preoperative variable associated with mortality Preoperative variable Mortality % if present Pulmonary failure 100 Cardiac failure 92 Requirement of > 2 antibiotics 82 Renal failure 73 Hepatic failure 66 Gastrointestinal bleeding 86 Required 2 nd operation 81 Positive cultures 61 Blood requirement > 2 units 69 Blood requirement < 2 units 22 Garrison RN, Cryer HM, Howard DA, Polk HC Jr. Clarification of risk factors for abdominal operations in patients with hepatic cirrhosis. Ann Surg 1984;199:

44 Anesthetic considerations

45 Anesthetic considerations The risk of surgery cannot be separated from the risk of anesthesia Anesthesia can affect the liver by reducing its blood flow.

46 Anesthetic considerations animals studies have shown that under the conditions of stress, hepatic blood flow increases to compensate for the reduced portal blood flow but patients with liver disease, especially cirrhosis, cannot compensate for the reduced portal blood flow, which may cause hepatic dysfunction

47 Anesthetic considerations In healthy volunteers, hepatic blood flow decreased by 35% to 42% in the first 30 minutes of induction of anesthesia

48 Anesthetic considerations The anesthetic agents Halothane and Enflurane reduce hepatic arterial blood flow These effects are minimal with Isoflurane Inhalational agents Isoflurane, Desflurane, and Sevoflurane undergo hepatic metabolism, extent of which is 0.2% for isoflurane, 2-4% for Enflurane, and 20% for Halothane Isoflurane has become the inhalation agent of choice in patients with liver disease

49 Anesthetic considerations Anesthetic agents, sedatives, and skeletal muscle relaxants can all have adverse effects The actions of neuromuscular blocking agents may be prolonged in patients with liver disease because of reduced pseudocholinesterase activity, decreased biliary excretion, and larger volume of distribution Metabolism of Atracurium is by Hoffman reaction and does not depend on liver Use of Atracurium is safe and is recommended in liver disease

50 Anesthetic considerations The use of various narcotics like fentanyl, sufentanil and sedatives like Oxazepam, Lorazepam, is recommended No correlation could however be established in patients with cirrhosis undergoing cardiac surgery and hepatic decompensation or mortality between the use of Enflurane, Isoflurane, Fentanyl, Sufentanil, Midazolam, or Morphine The type of anesthetic management either general anesthesia, regional anesthesia, or monitored anesthesia care did not affect the mortality in one of the largest reported series of 733 patients. Ziser A, Plevak DJ, Wiesner RH, Rakela J, Offord KP, Brown DL. Morbidity and mortality in cirrhotic patients undergoing anesthesia and surgery. Anesthesiology 1999;90:42-53

51 Conclusion Various type of surgeries can be safely performed in CTP score 7 CTP & MELD scores predict morbidity and mortality in cirrhotics In acute liver diseases surgery should be avoided Emergency surgery carries high mortality in cirrhotics

52 Conclusion Abdominal wall surgery may be safely performed in Child-Pugh in A & B Laparoscopic surgery should be preferred over open surgeries Asymptomatic GSD should not be operated

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