Management of Cirrhotic Patients Undergoing Non-Transplant Surgery

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1 Management of Cirrhotic Patients Undergoing Non-Transplant Surgery Jason S. Wakakuwa, M.D. Assistant Professor of Anesthesia Director, Transplant Anesthesia Beth Israel Deaconess Medical Center

2 I have no financial disclosures

3 Objectives Surgical risk assessment Pathophysiology Management strategies

4 Sample Patient 50 y.o. female with h/o Hep C cirrhosis in the ER with acute appendicitis. Alert and oriented X3 Mild ascites INR-1.7 Bil-2.1 Na-136 Creat.-1.0

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6 Child s Classification Class Points Mortality A 5-6 <10% B % C %

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9 Northup P, et al. Model for end-stage liver disease (MELD) predicts nontransplant surgical mortality in patients with cirrhosis. Ann Surg 2005.

10 Northup, 2005

11 Northup 2005

12 Northup 2005 Intra-abdominal

13 Teh S, et al. Risk factors for mortality after surgery in patients with cirrhosis. Gastroenterology abdominal 107 orthopedic 79 cardiovascular

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15 Etiologies of Cirrhosis Infectious Biliary Metabolic Toxins

16 Objectives Surgical risk assessment Pathophysiology Management strategies

17 Pathophysiology Focus on End Stage Liver Disease Review of organ systems

18 Pathophysiology Cardiovascular : Hyperdynamic state Pulmonary : Hepatopulmonary and Portopulmonary HTN Renal : Hepato-renal Syndrome GI : Portal HTN Varicies and ascites CNS : Encephalopathy Metabolic : Ca and Lactate metabolism

19 Hematologic Anemia nutrition, bleeding Hct : upper 20 s lower 30 s Thrombocytopenia splenomegaly Plt count : 50K -100K Coagulopathy INR : > 1.5

20 Coagulation 1 Hemostasis 2 Hemostasis

21 Vascular Endothelium Collagen

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26 Weisel, J. U Penn School of Medicine, 2009.

27 Components of Anti-Coagulation Tripodi A, Mannucci PM. N Engl J Med 2011;365:

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30 Hematologic Auto-anticoagulated or hypocoagulable Routine pre-procedure blood products A new approach born in mid 2000 s

31 Procoagulant Anticoagulant Liver synthesized II,V,VII,IX,X,XIII Fibrinogen Protein C&S Antithrombin ADAMTS13 Non-liver synthesized VWF VIII t-pa

32 Hematologic Tripodi A, et al. Evidence of Normal Thrombin Generation in Cirrhosis Despite Abnormal Conventional Coagulation Tests. Hepatology 2005.

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34 Tripodi A. Hepatology 2005

35 Failure to link abnl labs and bleeding Decreased Transfusion in Liver Transplants Presence of Venous Thrombosis NOT Hypocoagula ble Intraop Venous/Intracardiac Thrombosis

36 Bleeding Thrombosis Platelets Platelets ADAMTS13 VWF Pro-coagulants II,V,VII,IX,X Fibrinogen VIII Thrombin Anti-coagulants tpa XIII Protein C&S Antithrombin

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38 Coagulation Rebalance Lisman T, Porte R. Rebalanced hemostasis in patients with liver disease: evidence and clinical consequences. Blood Caldwell S, Intagliata N. Dismantling the myth of autoanticoagulation in cirrhosis: an old dogma dies hard. Hepatology Coagulopathy in Liver Disease, Padua, Sept

39 Objectives Surgical risk assessment Pathophysiology Management strategies

40 Anesthetic Plan Monitored anesthetic care Peripheral nerve blocks General anesthesia

41 Pharmacology Pharmacokinetics is highly variable Volume of distribution Protein binding Hepatic and/or renal clearance Titrate to effect, you can always give more

42 Anesthetic Induction Rapid sequence induction Laryngeal mask airway Appropriate pts with minimal ascites

43 Anesthetic Maintenance Oxygen/Air with a volatile agent Opioids not significantly affected Muscle relaxants very mild prolongation Propofol

44 Special Attention Adequate IV access Even in seemingly simple cases Intra-abdominal Torrential blood loss from varices Hemodynamic monitoring A line: frequent labs and PPV monitoring

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52 Fluid Management Lactated Ringers Plasmalyte or NS Albumin

53 Fluid Management Large volumes of intraop fluids will increase splanchnic venous pressure Variceal bleeding usually caused by high pressure and not coagulopathy Continued bleeding may be due to depletion of clotting factors

54 Fluid Management Most centers practice low volume transfusion Maintain renal function Maintain BP with pressors not fluid Massicotte L, et al. Effects of phlebotomy and phenylephrine infusion on portal venous pressure and systemic hemodynamics during liver transplantation. Transplantation 2010.

55 Principles Accurate risk assessment Knowledge of numerous pathophysiologic changes Reconsider belief of auto-anticoagulation Judicious use of IV fluids Be prepared with adequate IV access and monitoring

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