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
I have no financial disclosures
Objectives Surgical risk assessment Pathophysiology Management strategies
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
Child s Classification Class Points Mortality A 5-6 <10% B 7-9 10-30% C 10-15 30-75%
Northup P, et al. Model for end-stage liver disease (MELD) predicts nontransplant surgical mortality in patients with cirrhosis. Ann Surg 2005.
Northup, 2005
Northup 2005
Northup 2005 Intra-abdominal
Teh S, et al. Risk factors for mortality after surgery in patients with cirrhosis. Gastroenterology 2007. 586 abdominal 107 orthopedic 79 cardiovascular
Etiologies of Cirrhosis Infectious Biliary Metabolic Toxins
Objectives Surgical risk assessment Pathophysiology Management strategies
Pathophysiology Focus on End Stage Liver Disease Review of organ systems
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
Hematologic Anemia nutrition, bleeding Hct : upper 20 s lower 30 s Thrombocytopenia splenomegaly Plt count : 50K -100K Coagulopathy INR : > 1.5
Coagulation 1 Hemostasis 2 Hemostasis
Vascular Endothelium Collagen
Weisel, J. U Penn School of Medicine, 2009.
Components of Anti-Coagulation Tripodi A, Mannucci PM. N Engl J Med 2011;365:147-156.
Hematologic Auto-anticoagulated or hypocoagulable Routine pre-procedure blood products A new approach born in mid 2000 s
Procoagulant Anticoagulant Liver synthesized II,V,VII,IX,X,XIII Fibrinogen Protein C&S Antithrombin ADAMTS13 Non-liver synthesized VWF VIII t-pa
Hematologic Tripodi A, et al. Evidence of Normal Thrombin Generation in Cirrhosis Despite Abnormal Conventional Coagulation Tests. Hepatology 2005.
Tripodi A. Hepatology 2005
Failure to link abnl labs and bleeding Decreased Transfusion in Liver Transplants Presence of Venous Thrombosis NOT Hypocoagula ble Intraop Venous/Intracardiac Thrombosis
Bleeding Thrombosis Platelets Platelets ADAMTS13 VWF Pro-coagulants II,V,VII,IX,X Fibrinogen VIII Thrombin Anti-coagulants tpa XIII Protein C&S Antithrombin
Coagulation Rebalance Lisman T, Porte R. Rebalanced hemostasis in patients with liver disease: evidence and clinical consequences. Blood 2010. Caldwell S, Intagliata N. Dismantling the myth of autoanticoagulation in cirrhosis: an old dogma dies hard. Hepatology 2012. Coagulopathy in Liver Disease, Padua, Sept. 2013.
Objectives Surgical risk assessment Pathophysiology Management strategies
Anesthetic Plan Monitored anesthetic care Peripheral nerve blocks General anesthesia
Pharmacology Pharmacokinetics is highly variable Volume of distribution Protein binding Hepatic and/or renal clearance Titrate to effect, you can always give more
Anesthetic Induction Rapid sequence induction Laryngeal mask airway Appropriate pts with minimal ascites
Anesthetic Maintenance Oxygen/Air with a volatile agent Opioids not significantly affected Muscle relaxants very mild prolongation Propofol
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
Fluid Management Lactated Ringers Plasmalyte or NS Albumin
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
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.
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