Name of the = Speciality: ANAESTHESIA

Name of the=20 Speciality: = Anaesthesia =

Case: &n= bsp; &nbs= p; =20 =20 CIRRHOSIS &=20 PORTAL

&n= bsp; &nb= sp; &nbs= p; =20 HYPERTENSION

Name of the = Expert: =20 Ravinder Kumar Batra = Professor

and

&n= bsp; &nb= sp; &nbs= p; =20 Simica = Makkar

All India = Institute of=20 Medical Sciences, New Delhi: 110029

HISTORY=20

=95 =20 Nausea,=20 vomiting, anorexia, malaise, abdominal discomfort

=95 =20 Arthralgia=20 ,myalgia- acute viral hepatitis

=95 =20 H/o drug=20 exposure-CCl₄,vinyl chloride, acetaminophen ingestion, INH,=20

=20 methyldopa

=95 =20 H/o=20 contact with jaundiced patient, blood transfusion,=20 injections

=95 =20 H/o=20 Alcohol consumption, variceal bleeds, flapping tremors, ascites, weight = loss,=20 loss of libido, menstrual disturbances---suggestive of=20 cirrhosis

=95 =20 H/o travel=20 to hepatitis endemic area

=95 =20 Jaundice

=B7 =20 Budh-Chiari=20 syndrome

=B7 =20 Cirrhosis=20 of Liver- Jaundice is mild in jaundice

=B7 =20 Severe=20 jaundice indicateds associated biliary obstruction, alcoholic hepatitis = or=20 development of hepatocellular carcinoma

=95 =20 Hematemesis:=20 Indicates source of bleeding above the ligament of Treitz: fresh blood = or=20 altered, frequency and quantity are most important. More than 500ml is = called=20 severe hematmesis: Portal HT can be one of the causes if associated with = symptoms of ascites, jaundice, or hepatic encephalopathy. =

=95 =20 Malena:=20 Indicates that blood has been present in gastrointestinal tract for 12 = =96 14=20 hours, at least 60 ml blood is required to produce malena, black tarry, = foul=20 smelling stool is due to dgradation by GIT, It can be present for 4-7 = days after=20 treating the source of bleeding. Malena indicates the bleeding source is = fro=20 proximal intestine. Portal hypertension can be one of the causes if = symptoms of=20 ascites, jaundice or hepatic encephalopathy are = present..

=95 =20 Progressive=20 jaundice, dark urine, pale stools, pruritis, abdominal Pain - = extrahepatic=20 cholestasis

=95 =20 Low grade=20 fever, anorexia suggest tuberculosis

=95 =20 High fever=20 with chills, jaundice - cholangitis

=95 =20 Weight=20 loss=97neoplasm

=95 =20 Abdominal=20 Pain

=D8 = Diffuse=20 abdominal pain indicates development of bacterial=20 peritonitis

=D8 = Mild,=20 diffuse abdominal pain is also present in tuberculous=20 ascites

=D8 = Right=20 hypochndrium pain is due to stretching of Glisson capsule secondary to=20 hepatomegaly

=95 =20 Central=20 abdominal pain ,back pain, DM---Ca. = Pancreas

=95 =20 H/o=20 Abdominal Distension-

Ascites=20

=B7 =20 Sudden:=20 Acute Budh-Chiari syndrome, acute right heart failure, sudden = decmpensation of=20 previously decmpensated cirrhosis, Panacreatic ascites. =

=B7 =20 Insidious:=20 Decompensated cirrhosis of liver, chronic Budh-Chiari syndrome, = Tuberculosis,=20 Neoplasm, Hypoalbuminemia, Nephrotic syndrome, Hypothyroidism, right = heart=20 failure, and constrictive pericarditis.

=95 =20 Associated=20 Pedal Oedema: In congestive heart failure, oedema precedes ascites, = while in=20 cirrhosis of Liver usually abdominal distension precedes pedal=20 oedema.

Past=20 History

=D8 = H/o=20 alcohol intake

=D8 = No=20 significant family history or past h/o jaundice

=D8 = Hematemesis=20 or malena

Personal=20 History

=95 =20 H/o=20 alcohol intake

Examination

=95 =20 Pallor,=20 dry papery skin, scratch marks

=95 =20 Cachexia, clubbing =96 Biliary=20 cirrhosis

=95 =20 Pedal edema: bilateral in=20 cirrhosis

=95 =20 Lymphadenopathy:=20 Supraclavicular fossa- malignancy: size, site, localized or generalized, = number,=20 consistency, mobility, tenderness, matted or discrete, and overlying = skin should=20 be examined

=95 =20 Stigmata=20 of Chronic liver disease: Diminished body hair ( mainly in male, affects = face,=20 axilla, chest- due to increased level of circulating estrogen secondary = to=20 impaired liver function, = jaundice,=20 parotid enlargement- bilateral in cirrhosis: casue not known, spider = navi,=20 gynecomastia, Flushed extremities (palmar erythema), dilated veins = (caput=20 medusae), hyperdyanamic circulation, Dupuytren=92s contracture, Ascites, = Testicular atrophy ( Testis diameter less than 3mm and loss of normal = seeking=20 sensation while palpating the testis is called testicular atrophy =96 = due to=20 increased circulating estrogen), Flapping tremors and Fetor hepaticus ( = slightly=20 sweet, ammoniacal odour) should be examined

Abdominal=20 Examination:

Inspection: Contour=20 or shape of the abdomen, Flanks, Umbilicus, Abdominal movement, skin = over=20 abdomen, dilated veins, visible pulsation, visible mass, visible = peristalsis,=20 scars and sinuses, external genitalia

Palpation:=20 Tenderness, guarding, and rigidity, palpation of liver, spleen, kidney = and gall=20 bladder

Percussion: Horse=20 shoe dullness, Shifting dullness, Puddle sign to demonstrate minimal = fluid,=20 Dullness over lump

Auscultation: Bowel=20 sounds, arterial bruit, venous hum

Look=20 for:=20

=95 =20 Ascites (=20 distended abdomen, bulging flanks), Umbilicus stretched =96 transversely = in=20 ascites and vertically in ovarian cyst. Skin over abdomen- tense, shiny = and=20 transparent.

=95 =20 Hepatomegaly,=20 splenomegaly, pleural effusion

=95 =20 Right=20 upper quadrant tenderness, palpable gall bladder

=95 =20 Signs of=20 liver cell failure- parotid=20 swelling, dupuytrens contracture, gynaecomastia, fetor hepaticus, = asterixis,=20 testicular atrophy etc.

= Cardiovascular=20 system: =

=95 =20 Signs of = hyperdynamic=20 circulations may be present

= Respiratory=20 System:

=95 =20 Signs of = Hepatopulmonary=20 syndrome

Central = Nervous=20 System

=95 =20 Look for signs = of=20 Hepatic encephalopathy

=20

Questions for=20 Viva-voce:

Q. What is Cirrhosis of liver and = what is=20 its etiology?

Chronic = degenerative=20 process, replacement of = normal=20 tissue with hepatic fibrosis and nodular = regeneration

Etiology of=20 Cirrhosis

=96 =20 Alcoholic = liver=20 disease = 60-70%

=96 =20 Viral = hepatitis =20 10%

=96 =20 Biliary = disease 5-10%

=96 =20 Primary=20 hemochromatosis = 5%

=96 =20 Cryptogenic=20 cirrhosis 10-15%

=96 =20 Wilson=92s, = a1Anti Tryp. = Def, rare

&n= bsp; &nb= sp; &nbs= p; = ; =20 cardiac cirrhosis,etc

Q. How does = Alcohol=20 affect Liver?

Alcohol=20 causes:

=95 =20 Steatosis ( = Elevated GGT=20 +/- AST

=95 =20 Fibrosis = leading to=20 Cirrhosis ( High PT and low Albumin)

=95 =20 Hepatits ( = Elevated=20 Bilirubin)

=95 =20 Normal ( = Elevated=20 GGT)

Q. What are the features of = Chronic liver=20 disease?

=96 =20 Ascites

=96 =20 Jaundice

=96 =20 Palmer = erythema=20 (hyperdyanamic circulation)

=96 =20 Spider=20 angioma

=96 =20 Dupuyteran=92s = contracture

=96 =20 Parotid=20 enlargement

=96 =20 Diminished = body=20 hair

=96 =20 Testicular=20 Atrophy-increase estrogen levels

=96 =20 Gynaecomastia

=96 =20 Fetor = hepaticus=20 =96hepatic encephalopathy

=96 =20 Flapping=20 tremors

Q. What is = Spider=20 Angioma?

Spider Navi = (spider=20 angioma, vascular spider, arterial spider)-.

=96 =20 bright red = with a small=20 (1mm), central, red papule surrounded by several distinct radiating = vessels.=20

=96 =20 seen over face, neck, and upper = part of=20 the trunk, and arms.

=96 =20 Seen in = alcoholic liver=20 disease, pregnancy, thyrotoxicosis & women on oral contraceptive=20 drugs.

Pathogenesis=20

=96 =20 Increased = plasma levels=20 of estrogen, vascular dilation, and = neovascularization.

=96 =20 Generalized=20 hyper-dynamic circulation.

Q. What are the expected = hemodyanamic=20 changes in cirrhosis ?

HYPERDYANAMIC=20 CIRCULATION

Decreased = peripheral=20 vascular resistance=20
High Cardiac = output=20
Maintained = arterial=20 pressure, Heart Rate, filling pressures.
CAUSE of=20 Vasodilatation-endogenous =20 production or decreased hepatic clearance of vasodilators (NO,=20 glucagon, ferritin, VIP ,etc)=20
Total blood = volume=20 increased but, maldistributed (splanchnic hypervolemia, central=20 hypovolemia)=20
Increased O2 = content=20 in mixed venous blood, = decreased=20 (A-V)o2 content (mimic peripheral arteriovenous = fistula)=20
Cardiomyopathy/myocardial=20 contractile impairment=20
Diminished = response to=20 catecholamines=20
High Serum bilirubin affects = conducting=20 system leading to bradycardia, Complete Heart Block =

Q. Why these patients are = hypoxemic=20 preoperatively?

=95Rightward = shift of ODC=20 (increased 2,3DPG)

=95V/Q=20 mismatch: compressive = effect of=20 ascites, hepatomegaly, pleural effusion-basal

&n= bsp; &nb= sp; =20 atelectasis&increased = closing=20 volume

=95Impaired = Hypoxic=20 Pulmonary Vasoconstriction

=95Hepatopulmonary=20 syndrome =

=FC chronic liver = disease

=FCArt=20 hypoxemia

=FCIntrapulmonary = vascular=20 dilatation =E0 Platypnea- = orthodeoxia ( Patient = desaturates=20 in erct or sitting = position but=20 improves in recumbent position)

&n= bsp; =20 Increased (A-a)gradient, clubbing, spider=20 angioma

=95R=E0L = intrapulmulmonary=20 Shunts (vasodilators, NO, glucagon)

=95Decreased = pulmonary=20 diffusing capacity secondary to=20 increased Extra Cellular Fluid

=95Pulmonary=20 hypertension-PAP>25mm Hg associated with = portopulmonary

Syndrome worsened by = hypercapnia,=20 acidosis

Q. What = changes do you=20 expect in Haematological system?

=95Anaemia = - dilutional (increased plasma=20 volume)

&n= bsp; =20 - Gastrointestinal Bleed

&n= bsp; =20 - Megaloblastic anaemia (malnutrition, folate antagonism=20 ,alcohol)

&n= bsp; =20 -=20 Hypersplenism-hemolysis,

=95Thrombocytopenia=20 -=20 Hypersplenism

&n= bsp; =20 &n= bsp; -=20 Ethanol induced depression of bone marrow

=95Prolonged = PT,INR,aPTT=20 =96reduced synthesis of clotting factors

&n= bsp; &nb= sp; &nbs= p; =20 (first VII=E0V,X&II=E0I=20 )

=95DIC-accumulation = of=20 FDP

=95Enhanced = fibrinolytic=20 activity delyed = hepatic=20 clearance of plasminogen,activation

&n= bsp; &nb= sp; &nbs= p;=20 protien C,decr. synthesis of = inhibitors.=20

Q. What are = the GI=20 Manifestations of Cirrhotic?

Gastrointestinal=20 manifestations

=95 PORTAL HYPERTENSION & PS = shunting=20 leads to bleeding from Varices

=95 = ASCITES-Increased=20 intra-abdominal pressure =E0Resp.distress, = gastroesophageal

Reflex

Q. Define = portal=20 hypertension and what are the causes of it?

=95 =20 Portal HT - = pathological=20 increase in portal pressure

=95 =20 Portal pressue = gradient=20 (PPG- pressure gradient between the portal vein and inferior vena cava)=20

PPG ( mm of=20 Hg) =20 Sequlae

1 =96 5 =20 =20 =20 Normal

6-10 =20 =20 =20 Sub clinical PHT

>10 &nbs= p;=20 =20 Formation of oesophageal varices

>12 &nbs= p;=20 =20 Ascites, variceal bleeding

=95 =20 Transhepatic = PVP-8mmHg=20 above IVC pressure

=95 =20 Wedged = HVP-4-5mmHg above=20 IVC pressure=E0

=20 most = accurate in=20 intrahepatic postsinusoidal PH

Causes:

=96 =20 Pre-hepatic: = Portal V=20 thrombosis, Splenic V thrombosis, Extrensic compression of Portal V, AV=20 fistula

=96 =20 Intrahepatic: = Nodular=20 regenerative hyperpalsia, Non-cirrihotic portal fibrosis, = Schistosomiasis,=20 Primary biliary cirrihosis, Chronic hepatitis, Hemochromatosis, = Wilson=92s=20 disease, Alcoholic cirrihosis

=96 =20 Post-hepatic:=20 Budd-Chiari syndrome, IVC thrombosis, Constrictive pericarditis, = Tricuspid valve=20 disease

&nbs= p; =20 =20

Q. What is the = Clinical=20 Presentation of Portal HT?

=95 =20 Splenomegaly = and=20 hypersplenism

=95 =20 Ascites

=95 =20 Hematemesis = &=20 malena

=95 =20 Encephalopathy

Q. What are = the=20 different sites of Varices and how will you = manage

bleeding=20 Varices?

Due to = elevated=20 pressures in veins that drain into portal system=E0 portosystemic = collaterals=E0=20 varices

=95 =20 Esophageal,

=95 =20 Gastric,

=95 =20 Hemorrhoidal = most=20 commonly ( periumblical, retroperitoneal)

Treatment of = VARICEAL=20 BLEEDING:

Resuscitation at=20 emergency presentation

=95 Treat = hemorrhagic=20 shock: Crystalloid + colloids + Red Cells +=20 FFP

=95Goal: Tissue=20 Perfusion

=95Monitor: Urine = Output

Management of = variceal=20 bleeding

=95 =20 Treatment of=20 cause

Medical=20 management

=D8 = Splanchnic = Vasoconstrictors- =20 Octreotide,Somatostatin

=D8 = Generalised = vasoconstriction-=20 Vasopressin + nitroglycerine

=D8 = Propranolol prophylaxis = of=20 rebleed.

Surgical=20 treatment:

=D8 = Endoscopic sclerotherapy, = banding,=20 balloon tamponade

&n= bsp; (Sengstaken=20 Blakemore tube) - (Endotracheal intubation is = usually

&n= bsp; =20 required

&n= bsp; &nb= sp;=20 in acutely bleeding patients for airway protection during = placement=20 of

&n= bsp; &nb= sp; =20 SB tube.)

=D8 = Shunt=20 surgery

1. = Nonselective (portocaval &proximal = splenorenal=20 shunts) =E0 can

precipitate=20 encephalopathy.

2. Selective (decompress = only=20 varices)

3.=20 TIPS

Q. How will = you assess=20 Ascites?

ASSESSMENT:

=95 =20 Palpation: = Fluid thrill=20 (Severe ASCITES)

=95 =20 Percussion:=20

=96 =20 Shifting = dullness=20 (MODERATE ASCITES)

=96 =20 Horse-shoe=20 dullness

=96 =20 Puddlensign-=20 120ml:=20 U/S abd can detect as little as 100ml of = fluid.

Q. What is the = Pathogenesis of Ascites and how will you treat = it?

Pathogenesis:

=B7 =20 Underfilling=20 theory

=B7 =20 Overfill=20 theory

=B7 =20 Peripheral=20 arterial vasodilatation hypothesis

Treatment of=20 Ascites:

=B7 =20 Ascites due to = cirrhosis high SAAG=20 >1.1g/dl

=B7 =20 Strict bed=20 rest

=B7 =20 Sodium = restriction NaCl = <2g/day

=B7 =20 Spironolactone (antialdosterone=20 effect)

=B7 =20 TIPS, = side-to-side=20 portocaval shunt, paracentesis

=B7 =20 Albumin to = increase=20 plasma oncotic pressure

Q. What = changes occur in=20 renal system?

Hepatorenal=20 syndrome -functional renal damage = follows=20 aggressive diuresis,

=20 (HRS) &n= bsp; =20 Gastrointestinal=20 bleed, sepsis, major = surgery=20 =E0

Oliguria=20
Elevated=20 creatinine(>1.5mg/dl)=20
Low urine=20 sodium(<10meoq/L)=20
Benign = urinary=20 sediment

HRS = differentiated from=20 prerenal failure by lack of = response to=20 1.5Lvolume challenge

Acute Tubular = Necrosis=20 differentiated by urine = sodium>30meq/L=20 &granular casts in urinary sediment.,urine/plasma=20 creatinine<20:1

Pathogenesis:

intense = renal=20 vasoconstriction , activation of renin angiotensin system in response to decrease in = effective=20 plasma volume in cirrhosis.

=95 =20 Kidney = refractory to=20 ANF, renal prostaglandins(avoid NSAIDS)

=95 =20 Rightward = shift of renal=20 autoregulatory curve (avoid decrease in MAP) =

Treatment: =

Hydration,=20
Avoid = overzealous=20 diuretics,
Mannitol(controversial)=20
Liver=20 transplantation

Q. What type = of=20 Electrolyte imbalance do you find in these = cases?

=D8 = Hyponatremia = =96increased=20 ADH, impaired renal handling of free water, overaggressive diuretic use, = low=20 sodium diets

Treatment = :Discontinuation of=20 diuretics &free water restriction

&n= bsp; =20 (not = hypertonic saline , = not>12meq/day=E0risk=20 of

&n= bsp; &nb= sp;=20 centralpontine=20 myelinolysis)

=D8 = Hypokalemia = =96diuretic=20 use, intestinal losses, hyperaldosteronism

=D8 = Hyperkalemia-=20 spironolactone, renal failure, metabolic acidosis.

=D8 = Metabolic = acidosis/=20 compensated respiratory alkalosis-hyperventilation due to centrally acting = hormones,/met=20 alkalosis-loop diuretics, hyperaldosteronism, Vomiting,=20 diarrhea

=D8 = Hypoglycemia-decreased=20 glycogen reserves,alcohol induced glycogenolysis, depletion due to=20 malnourishment.

Q. What are = the=20 alternation in drug metabolim found in these cases = ?

&nbs= p; =20

Alteration in = drug=20 metabolism

Drugs are=20 metabolized in two phases in liver:

PHASE1-oxidation=20 (cytP450), r=E9duction, hydrolysis(LA)

PHASE2-=20 conjugation, glucouronidation (=20 bilirubin,morphine,aminophylline,loraxepam)

# Phase 1 = affected=20 earlier in liver dysfunction

Pharmacokinetic changes=20 caused by liver disease:

=FCReduced=20 HBF

=FCAltered = protein binding=20 (manifested at albumin levels <2.5 mg/dl)

=FCAltered = metabolic=20 activity

=FC Increased = volume of=20 distribution-hyperdynamic circulation

=FCRenal=20 clearance

=FCPortosystemic=20 shunting

Drug=20 Clearance:

=95CL=3DQE(Q-liver blood=20 flow, E-extraction ratio)

=D8High = extraction=20 ratio=E0clearance = approaches=20 Q,(flow limited drugs(E>0.7)- lidocaine,

pethidine,=20 morphine,propranolol, =20 labetalol,nitroglycerine, verapamil=E0influenced=20 by

changes in liver blood flow = ,also by=20 shunting of blood around liver.:

REDUCE DOSE, BUT NOT FREQUENCY OF=20 DOSING.

=D8 =20 Low extraction = ratio=E0clearance = depends on=20 rate of metabolism(capacity limited=20 drugs(E<0.3)-diazepam,phenytoin,warfarin)=E0influenced by = free=20 fraction of drug & free intrinsic drug = clearance:

= LENGTHEN TIME = BETWEEN=20 DOSE ADMINISTRATION , BUT NOT DOSE.

Pharmacodynamic=20 changes=20 :

=95 =20 CNS = sensitivity to=20 opioids & sedatives is increased;

=95 =20 Effects of = anticoagulant=20 increased

=95 =20 Fluid & = electrolyte=20 imbalance: Na retention more readily induced by NSAIDs / = corticosteroids;=20 ascites & oedema may be more resistant to = diuretics

Q. What are the factors affecting = Hepatic=20 Blood flow?

Factors = affecting=20 Hepatic blood flow:

Normal Hepatic = blood=20 flow-100ml/100g/min;

1200-1400 ml/min( 25%=20 C.O.)

&n= bsp; =20

&n= bsp; =20 &n= bsp; Bld.=20 Supply = O2=20 supply = SpO2 Mean=20 pr.

Hepatic Artery = 25-30% =20 45-50% =20 98% =20 40-70mmhg

Portal = Vein =20 70-75% =20 50-55% =20 60-75% =20 7-10mmhg

Factors = affecting=20 Increase in Liver Blood flow

=D8 =20 Hypercapnia

=D8 =20 Acute=20 hepatitis-viral,alcoholic

=D8 =20 Supine=20 posture

=D8 =20 Food

=D8 =20 Beta=20 adrenostimulation

=D8 =20 Phenobarbitone

=D8 =20 Enzyme=20 inducers

Factors = affecting=20 Decrease in Liver Blood flow

=D8 =20 IPPV+PEEP

=D8 =20 Abdominal=20 surgery

=D8 =20 Hypocapnia,Hypoxia

=D8 =20 Cirrhosis

=D8 =20 Upright=20 posture

=D8 =20 Anaesthetics-volatile=20 & intravenous

=D8 =20 Alphaadrenostimulation

=D8 =20 Beta=20 blockade

=D8 =20 Ganlion=20 blockade

=D8 =20 cimetidine

Q. What are = the=20 Neurological Manifestations of Cirrhosis of = Liver?

Neurological=20 manifestations

Hepatic=20 encephalopathy-neuropsychiatric syndrome

= Grade &n= bsp; =20 mental status = asterixis# = EEG

=20 1 =20 Drowsy but oriented, =20 +/- &n= bsp;=20 Normal

&n= bsp; =20 mild confusion

=20 2 &n= bsp;=20 Drowsy,disoriented =20 + =20 &n= bsp;High=20 voltage

&n= bsp; =20 &n= bsp; &nb= sp; &nbs= p; = ; &n= bsp; Slow=20 wave

= 3 =20 Agitated,aggressive &n= bsp;=20 + =20 Abnorma= l

=20

= 4 &n= bsp;=20 Coma,unresponsive to + =20 Abnorma= l

= &n= bsp; deep painful=20 stimuli

# Shifting = combination=20 of asterixis, hyperreflexia, extensor plantar

=95 =20 Mechanism- = portasystemic=20 shunting=E0ammonia, = mercaptans,=20 endogenous BZD

=95 =20 Precipitating=20 factors-increase N2 load- Gastrointestinal Bleed,

=20 -Diuresis (hypokalemia, hyponatremia)

=20 -Narcotics,sedatives

=20 -TIPS

=20 -Excess protein intake

=20 -Azotemia

Treatment:

&n= bsp; =20 - Restrict protein = intake(<60g/d)

&n= bsp; =20 - Neomycin500mg qid (nephrotoxicity,ototoxicity)=E0decrease=20 bacteria=E0 =

&n= bsp; =20 ↓ ammonia synthesis

- =20 Lactulose = 30-120 ml,tds=20 until 4 stools/d=E0decrease pH of = colon =

= NH3=20 =E0NH4+ thus = reducing=20 absorption ,osmotic=20 laxative

Surgical = options in=20 these patients:

=B7 =20 Sclerotherapy = for=20 varices

=B7 =20 Shunt=20 surgery

=B7 =20 Emergency non = hepatic=20 surgery

=B7 =20 Liver = transplant=20 surgery

Q. How will = you prepare=20 these patients for surgery?

Preoperative=20 assessment

=95 =20 History, signs = of liver=20 dysfunction

=95 =20 Type & = degree of=20 liver dysfunction

=95 =20 Risk = assessment,ASA=20 grading

=95 =20 Investigations

=95 =20 Drugs- = spironolactone,=20 neomycin Vit K, β-blockers, = steroids,=20 antacids, etc

=95 =20 Associated = medical &=20 surgical problems-HRS-(assess hydration, assess veins ),ascites ,GI = bleed,=20 encephalopathy, hypoxemia (HPS), cardiomyopathy, effects of alcoholism, = sepsis,=20 coagulopathy.

=95 =20 Consideration = for=20 altered drug pharmacokinetics

Q. What = Investigations=20 would you advice for these patients?

Investigations:

=95 =20 Haemogram,=20 PCV

=95 =20 PT/albumin/bilirubin

=95 =20 SGOT/SGPT/LDH = ,=20

=95 =20 Alkaline = phosphatase,=20 GGT =96

=95 =20 Electrolyte=20 (Na,K,ionised Ca)/ = Renal function/Glucose/Ammonia =

=95 =20 PT/PTT = /INR/platlet=20 count

=95 =20 ABG/PFT/X-ray chest=20

=95 =20 ECG

=95 =20 ECHO

=95 =20 USG=20 abdomen,splenovenogram(portal venous pressure),upper g.i.=20 endoscopy,

=95 =20 Viral = markers-Hep B=20 & C

Q. How will = you grade=20 risks in these patients?

Child & = Turcotte=20 Classification of liver disease

Group

Serum = bilirubin=20 (mg/dl)

<=20 2.0

2.0 =96=20 3.0

>=20 3.0

Serum = albumin=20 (g/dl)

>=20 3.5

3.0 =96=20 3.5

<=20 3.0

Ascites

None

Easily=20 controlled

Poorly=20 controlled

Encephalopathy

None

Minimal

Advanced

Nutrition

Excellent

Good

Poor

1-4sec

4-6sec

>6sec

Mortality=20 rate

2 =96 5=20 %

10=20 %

50=20 %

Elective = surgery=20

=D8 =20 Tolerated in = Child=92s A=20 cirrhosis

=D8 =20 Permissible = with=20 preoperative preparation in Child=92s B (except extensive hepatic = resection &=20 cardiac surgery)

=D8 =20 Contraindicated in=20 Child=92s C cirrhosis

MELD

Model = for=20 End-Stage Liver Disease

=D8 =20 Accurately = estimates 3=20 month mortality in patients with cirrhosis

=D8 =20 Bilirubin, = INR,=20 Creatinine

=D8 =20 (3.8 X In = bilirubin=20 value) + (11.2 X In INR) + (9.6 In Creatinine = value).

=D8 =20 Range 6-40, = relative=20 risk increases 100 times from &n= bsp; &nb= sp; =20 &n= bsp;

=20 8=E0 30=20

GARRISON=92S = risk factors=20 for postoperative mortality in cirrhotic = patients

=95 =20 Serum=20 albumin<3g/L

=95 =20 Presence of=20 infection

=95 =20 WBC=20 count>10,000

=95 =20 Treatment with = more than=20 2 antibiotics

=95 =20 Prothrombin=20 time>1.5sec over control

=95 =20 Serum=20 bilirubin>50mmol/L

=95 =20 Presence of = ascites=20

=95 =20 Malnutrition

=95 =20 Emergency=20 surgery

Q. What = preoperative=20 preparations you will advice in this case?

Preoperative=20 Preparations

=95 =20 Informed high = risk=20 consent

=95 =20 Arrange for = postop.=20 Ventilation & ICU care

=95 =20 Blood grouping = cross=20 matching, FFP

=95 =20 NPO=20

=95 =20 Hydration- catheterize=96 u.o. = >1ml/kg/hr,correct=20 electrolyte imbalance.

=95 =20 Correct = coagulopathy=20 - vit K(resolves in cases = of=20 obstructive jaundice),FFP,platelets

=95 =20 Correct = anaemia to a=20 Hct of = 30%

=95 =20 Mgt. of = ascites-=20 paracentesis,Na & water restriction, diuretics(weight loss of 0.5 = kg/d)

=95 =20 Prevent HRS- = avoid=20 dehydration,avoid NSAID=92s, aminoglycosides, aggressive diuresis, = contrast=20 agents,etc.

=95 =20 Avoid = iatrogenic factors=20 of encephalopathy-long acting BZD, opioids

=95 =20 Lactulose and = neomycin=20 to limit bacterial toxins

=95 =20 Thiamine in acute alcoholic withdrawal, = prophylaxis for delerium tremens

Q. What are = the=20 Anaesthetic goals in this patient?

Anaesthetic=20 goals:

=95 =20 Maintain = physiology of=20 liver and kidney

=D8 = Maintain O2 = supply=20 =96demand ratio=E0adequate pulm. = Ventilation, maintain C.O.& circulating volume

=D8 = Maintain renal = perfusion- avoid = hypotension,=20 hypoproteinemia, decr. Pao2

=95 =20 Choose = appropriate=20 anaesthetic agent

=95 =20 Avoid = hypoglycemia,=20 hypothermia

=95 =20 Aggressive = replacement=20 of blood loss.

Q. What your = Choice of=20 Anaesthesia?

Choice of=20 anaesthesia

General = Anaesthesia=20 versus Regional

=95 =20 Higher level = of block=20 required , extensive block can result in = hypotension

=95 =20 Hypotension = & blood=20 loss poorly tolerated due to reduced sensitivity to vasopressors = (Dopamine=20 is vasopressor of choice = as it=20 does not reduce HBF)

=95 =20 Regional = contraindicated=20 inCoagulopathy if PT =20 >2.5sec above control

=95 =20 Epidural advantageous over spinal of = less=20 hypotension &extended postoperative analgesia

Q. What = premedication=20 would you advice for this patient?

Premedication

Oral = premedication=20 preffered to intramuscula.=E0 as coag. = Profile=20 deranged

=95 =20 Anxiolysis=E0If = neurological status=20 normal-

&n= bsp;=20 oral Lorazepam(phase II metabolism),short acting temazepam=20

=95 =20 Aspiration=20 prophylaxis=E0ranitidine,metoclopramide

=95 =20 Opioids-mild/mod liver=20 dysfunction fentanyl1-2μg/kg

=95 =20 Phenothiazines = avoided.

=95 =20 Vit K ( slow = i.v.)=20 continue till morning

=95 =20 If on steroids = ,continue=20 supplementation perioperatively.

=95 =20 If bilirubin=20 high=E0 prophylactic = mannitol=20 1g/kg 10%(role controversial), ERCP/External biliary=20 drainage.

=95 =20 Large bore = i.v.=20 cannulae, CVP line (triple lumen internal jugular) after excluding = coagulopathy=20

=95 =20 I.V fluids- = while=20 fasting 1-2ml/kg/hr, catheterize evening before surgery & maintain=20 u.o.->1ml/kg/hr

Q. What is = your=20 Anaesthetic Technique for Major abdominal surgery = in

this=20 patient?

Anaesthetic = technique=20 :

=95 =20 Cockpit=20 drill

=95 =20 Preoxygenation

=95 =20 Induction-Thiopental3-4mg/kg/propofol=20 2mg/kg (slow titrated doses)

=95 =20 Rapid sequence = induction-succinylcholine1mg/kg

=95 =20 Smooth, gentle = intubation, low volume high pressure cuff ETT

=95 =20 Mantainance:remifentanyl/fentanyl

=95 =20 IPPV+/-PEEP,isoflurane/O2/N2O(higher=20 than normal fio2=E0because of=20 intrapulmonary shunts),PacO2-35-40mmHg

=95 =20 Fluids-crystalloid=20 1-2ml/kg/hr,aggressive replacement of blood loss.

=95 =20 Avoid = hypotensive=20 anaesthesia

Alteration in = specific=20 drug pharmacokinetics

Thiopentone=20 :

=D8 =20 Decreased = Protein=20 binding=E0 reduced=20 dosage

=D8 =20 Reduction in = cytochrome=20 P activity & altered redistribution=E0 t =BD=20 prolonged.

&n= bsp; &nb= sp; =20 Total body clearance unaffected in = cirrhosis

=D8 =20 Cumulation of repeated=20 doses

=D8 =20 Alcoholic=E0higher = doses(cross=20 tolerance)

=D8 =20 SLOW TITRATED = DOSES TO=20 BE GIVEN

PROPOFOL:

=D8 =20 Glucouronide = conjugation=20 to inactive metabolites

=D8 =20 Extrahepatic = sites of=20 metabolism as clearance exceeds HBF

=D8 =20 17% decrease = in hepatic=20 blood flow (↓ BP, ↓SVR)

=D8 =20 CARE IN CVS=20 INSTABILITY

MUSCLE=20 RELAXANTS

=95 =20 INCREASED = INITIAL DOSES,=20 RECOVERY SLOWER ( increased ⁭ Volume of distribution, reduced=20 clearance)

SUXAMETHONIUM: =

=D8 =20 Pseudocholinesterase=20 levels reduced, but action seldom prolonged

ATRACURIUM : = RELAXANT OF=20 CHOICE

=D8 =20 Hoffman=20 degradation,independent of liver metabolism

=D8 =20 Increased = binding to=20 raised globulin levels=E0increased = resistance and=20 a shorter duration of action.

VECURONIUM=20 :

=D8 =20 reduce hepatic = uptake(exceeded at doses greater than 0.15mg/kg)

=D8 =20 40% hepatic = metabolism,decreased=20 clearance

PANCURONIUM:

=D8 =20 10-20% liver = metabolism,=20 reduced hepatic uptake, clearance ↓, t_1/2=20 prolonged.

ROCURONIUM

=D8 =20 eliminated = predominantly=20 by liver, action prolonged,clearance ↓.

MIVACURIUM

=D8 =20 reduced plasma = cholinesterase

Inhalational=20 anaesthetics

Isoflurane- AGENT OF = CHOICE=20

&n= bsp; Hepatic autoregulation = mantained, Hepatic=20 arterial blood flow increased,

&n= bsp; =20 while decreasing (or not = changing=20 portal blood flow)

&n= bsp; =20 0.2% hepatic metabolism, less risk of immunoallerginic=20 hepatitis.

Sevoflurane = &=20 Desflurane

&n= bsp; Maintain = hepatic arterial=20 blood flow

Enflurane=20

Reduced Portal = Vein=20 Flow>Hepatic Artery flow

Halothane-

=95 =20 ↓ portal = venous blood=20 flow(reciprocity impaired)

=95 =20 Reduce hepatic arterial blood = flow &=20 oxygen supply ( Hepatic A = resistance,

= systemic=20 vasodilatation, slight negative inotropic effect)

=95 =20 Reduce hepatic = clearance=20 of drugs with high hepatic extraction ratio- lignocaine, morphine, = meperidine,=20 etc

=95 =20 20% liver=20 metabolism,halothane hepatitis.

=20 Analgesics

Remifentanyl - = Drug Of=20 Choice

=96 =20 hydrolysed by = non=20 specific plasma & tissue esterases,

=96 =20 clearance = independent of=20 liver and renal function

Fentanyl:=20

=96 =20 mantains = hepatic oxygen=20 supply-demand ratio

=96 =20 Normal half = life in low=20 doses, accumulation in high doses.

Morphine & = meperidine = .

=96 =20 Metabolism = reduced due=20 to ↓ hepatic blood flow =20

Alfentanyl-

=96 =20 High protein = binding=20 ,low extaction ratio,prolonged t1/2 in alcoholic cirrhosis,not affected by=20 renal

NSAIDS not adviced=20 =E0 ill effects = on git ,=20 platelets and renal function

Q. What your = Choice of=20 Fluid in these patients?

Choice of = fluid &=20 blood replacement?

=95 =20 Intravenous = colloid=20 fluids for hypotension

=95 =20 Na containing = fluids=20 with caution, due to presence of Na retention(serial Na=20 monitoring)

=95 =20 Albumin to = correct acute=20 ascitic fluid drainage

=95 =20 Fresh whole = blood=20 prefered to stored blood

=95 =20 Risk of = hypocalcemia due=20 to deranged citrate metabolism

=95 =20 Mannitol/furosemide/dopamine=20 if u.o<1ml/kg/hr

Q. What = Intraoperative=20 Monitoring you would do in this patient?

=20 Monitoring

=95 =20 Standard-BP = (non=20 invasive,Pulse,ECG Etco2,spo2, core temperature ,urine output, blood=20 loss)

=95 =20 CVP, PCWP, = invasive=20 BP

=95 =20 Neuromuscular=20 monitoring(TOF)

=95 =20 Bleeding = /clotting=20 studies-PT,PTT,ACT,TEG

=95 =20 ABG, = S.electrolytes=20 (Na,K,ionized Ca),blood sugar

Q. How will = you=20 manage these patients postoperatively?

Reversal

=95 =20 Extubated when = awake,fully responsive

=95 =20 Elective=20 postop.ventilation reqd.:

=D8 =20 Extensive = surgery in=20 severe liver disease

=D8 =20 Associated = pulm. or=20 cardiac disease

=D8 =20 Spo2<90% = with fio2=20 0.4

=D8 =20 Impaired=20 consciousness

=D8 =20 Fluid & = electrolyte=20 imbalance, hypothermia. =20

=95 =20 Elective=20 ventilation, or oxygenation for at least 12-16 hrs.=E0 = CPAP ,=20 Physiotherapy

=95 =20 U.O.1-2ml/kg/hr, dopamine=20 & mannitol to be continued for 36 hrs postop.

=95 =20 Antibiotic=20 coverage

=95 =20 Analgesic-epidural,=20 if coag profile normal; epidural morphine /bupivacaine+fentanyl; i.v. infusion of morphine = PCA=92sor=20 fentanyl,i.m injections avoided.

=95 =20 ICU care=20 & monitoring.(fluid=20 ,electrolyte,hypothermia)

Q. What=20 are the postoperative complications in these = patient?

Postoperative=20 complications

=95 =20 Impaired=20 consciousness (oversedation)

=95 =20 Impaired=20 respiration(opioid overdose)

=95 =20 Inadequate=20 reversal

=95 =20 Chest=20 infection

=95 =20 Oliguria=20 and renal failure

=95 =20 Deterioration=20 of liver function

Q. What are = the problems=20 in this case for Liver Transplantation?

Anaesthesia = for liver=20 transplantation

Problems:

=D8 =20 Multisystem=20 nature of cirrhosis

=D8 =20 Massive=20 blood loss(coag. defects, preop.thrombocytopenia,previous abd.=20 Surgery)

=D8 =20 Hemodyanamic=20 consequences of clamping & unclamping IVC

=D8 =20 Metabolic=20 consequences of anhepatic phase

=D8 =20 Risk of=20 air embolism(avoid N2O) & hyperkalemia in neohepatic=20 phase.

Preanhepatic=20 phase(dissection):=20

CVS = instability=20 due to haemmorhage,venous

pooling(sudden decreases = in=20 IAP),reduced venous return(surgical retraction)

Anhepatic=20 phase:

HA,PV,IVC clamped, native liver = removed=E0

=FC =20 Marked=20 hypotension(reduced VR)-inotropes =20 & fluids reqd.=97venovenous bypass utilized(IVC/PV to = axillary=20 v.1-3L/min)

=FC =20 Hypocalcemia-large=20 citrate load from BT not metabolized

=FC =20 Metabolic=20 acidoisis-acid metabolites from lower body not cleared by=20 liver(NaHco3,THAM)

=FC =20 Hyperglycemia(from=20 transfused blood products)

Neohepatic=20 phase:

=FC =20 Air=20 embolism (pulmonary & systemic)

=FC =20 Hypothermia

=FC =20 Hyperkalemia

=FC =20 Metabolic=20 acidosis

=FC =20 Thromboembolic=20 phenomenon during reperfusion

=FC =20 Hyperfibrinolysis

Postoperative=20 problems

=D8 =20 Haemorhage,fluid=20 overload,metabolic alkalosis ,hypokalemia

=D8 =20 Respiratory=20 failure, pleural effusion, rt phrenic n. injury,

=D8 =20 Renal=20 failure

=D8 =20 Thrombosis=20 hepatic & portal vessels

=D8 =20 Cyclosporine=20 toxicity (neurological & nephropathy)

=D8 =20 Life=20 threatening infections (fungal, viral)

=D8 =20 Graft=20 rejection.