Peri-op
CHRONIC LIVER DISEASE
*Perioperative morbidity and mortality is significantly increased in patients with chronic liver disease; the degree of increased surgical risk correlates with the severity of the liver disease.
CHILD'S-PUGH SCORING CLASSIFICATION FOR SEVERITY OF CHRONIC LIVER DISEASE:
1 POINT 2 POINTS 3 POINTS
Albumin >3.5 2.8-3.5 <2.8
Ascites none easy control moderate to poor
Encephalopathy none grade 1-2 grade 3-4
Protime INR <1.7 1.7-2.3 >2.3
TBilirubin <2.0 2.0-3.0 >3.0
(For PBC or PSC <4 4-10 >10)
*Class A = 5-7 points, Class B = 8-10, Class C = 11-15
MANAGEMENT:
1) Hemostasis-give Vitamin K to correct any degree of vitamin K deficiency; give FFP for major surgery if protime INR elevated at 1.5 or more and give platelets if count is under 50,000.
2) Avoid benzodiazepines completely (unless patient is experiencing active alcohol withdrawal).
3) Narcotic dosing is generally lower due to enhanced effect and diminished clearance.
4) Lactulose can be given for any evidence of encephalopathy, either by mouth or by retention enema.
5) Avoid nephrotoxic agents, such as gentamicin (which may precipitate hepatorenal syndrome).
6) Dextrose infusion to avoid hypoglycemia, especially post-op until the patient is eating again.
7) Improvement of nutritional status is desirable but usually difficult to achieve in the short-term. TPN might be beneficial in this regard, but be aware that amino acid infusion may precipitate encephalopathy and that intralipid infusion may exacerbate cholestasis. Albumin infusion is useless from a nutritional standpoint but may be beneficial to mobilize extravascular fluid, if this is the intent. For alcoholic liver disease, daily thiamine, multivitamin, and folate are typically recommended. (If maintenance IVF is given, I usually order thiamine 100mg, MVI one amp, folic acid 1mg, and MgSO4 1gm all added to the first bag of IVF daily.)
8) Anesthesia-if at all possible, avoid general anesthesia in patients with advanced liver disease. As a rule, the inhalational agents decrease portal and hepatic blood flow and are more likely than non-inhalational agents to worsen hepatic function.
