Anesthesia for Diseases of the Liver

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Anesthesia for Diseases of the Liver
2015-09-21 21:22:25
Anesthesia Diseases Liver

Anesthesia for Diseases of the Liver
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  1. Acute Hepatitis
    • Mild hepatitis: Aminotransferase Concentrations <500IU/L 
    • Anemia and lymphocytosis are typically present
    • Specific etiology determined by serologic testing
  2. Drug Induced Hepatitis
    • Acetaminophen Overdose: Discontinue and give N-acetylcysteine within 8 hours. 
    • Volatile Anesthetics: May produce mild, self-limiting post liver dysfunction due to hepatic oxygen supply. Halothane hepatitis may be due to an immune-mediated hepatotoxicity.
  3. Differential of Postoperative Hepatic Dysfunction
    • Types: Prehepatic, Intrahepatic (hepatocellular), Posthepatic (cholestatic)
    • Labs: Bilirubin, aminotransferase, alkaline phosphatase
    • Differential based on labs: Drugs, sepsis, increased exogenous bilirubin (blood transfusion), hematoma, Hemolysis, benign postoperative hepatic cholestasis, immune related hepatotoxicity, check preoperative records for hypotension, hypoxemia, hypoventilation, and hypovolemia
  4. Prehepatic Dysfunction
    • B:Increased unconjugated
    • ALT/AST: normal
    • AlkPhos: normal
    • Causes: hemolysis, hematoma, bilirubin overload from blood transfusion
  5. Intrahepatic (hepatocellular dysfunction)
    • B: Increased conjugated
    • ALT/AST: Increased
    • AlkPhos: N/slightly increased
    • Causes: viral, drugs, sepsis, hypoxemia, cirrhosis
  6. Posthepatic (cholestatic)
    • B: Increased conjugated
    • AST/ALT: N/slightly increased
    • AlkPhos: Increased
    • Causes: sepsis, biliary tract stones
  7. Chronic Hepatitis
    • Commonly viral (HBV/HCV) or immune
    • AST/ALT: elevated
    • B: Normal w/viral and increased w/autoimmune
    • Severe: decreased albumin and prolonged PT
    • Immune: Increased gamma globulin, tx w/ corticosteroids and azathioprine
    • HBV: age at initial infection is major determinant of chronicity
    • HCV: Most common
  8. Liver Cirrhosis: Info and Types
    • Causes: alcoholism, postnecrotic (viral, autoimmune, cryptogenic), primary biliary, hemochromatosis, Wilson's Disease, alpha1 antitrypsin deficiency, nonalcoholic steatohepatitis, 
    • Decreased hepatic blood flow due to increased resistance through the portal vein (portal HTN). This leads to an increased proportion of hepatic blood through the hepatic artery 
    • A: decreased
    • PT: prolonged
    • AST/ALT: increased
    • AlkPhos: Increased
  9. Liver Cirrhosis: Complications
    • Portal HTN: increased resistance through the portal venous system
    • Gastroesophageal Varices: tracheal intubation may be needed to prevent aspiration of blood. Bleeding = 1/3 of deaths due to cirrhosis
    • Ascites: Tx w/ spironolactone
    • Hyperdynamic circulation: Increased CO due to peripheral and splanchnic vasodilation, increased IV fluid, decreased blood viscosity (anemia), and arteriovenous communications. 
    • Cardiomyopathy:
    • Anemia: 
    • Coagulopathy:
    • Arterial hypoxemia: PaO2 60-70mmHg
    • Hetatorenal syndrome: functional renal failure w/o intrinsic abnormality of the kidneys.  
    • Hypoglycemia: Inability to convert lactic acid to glucose. 
    • Duodenal Ulcers:
    • Gallstones:
    • Spontaneous bacterial peritonitis:
    • Hepatic encephalopathy:
    • Primary hepatocellular carcinoma:
  10. Liver Cirrhosis: Anesthesia Preoperative
    • Identify problems that can be optimized preoperatively (cardiorespiratory function, coagulation, renal function, IV fluids, electrolyte balance, malnutrition).
    • Vitamin K if prolonged PT.
    • Chronic alcoholism increases MAC. 
    • Acute alcohol intoxication: Decreased MAC requirement, increased regurgitation risk, platelet interference,
  11. Liver Cirrhosis: Anesthesia Intraoperative
    • Hepatic flow seems maintained during admin of volatiles (except halothane)
    • IV anesthetics are valuable w or w/o N2O. 
    • Muscle relaxants: Hepatic clearance must be considered. Ascites causes a higher dose needed. Cisatracurium elimination is not affected.  
    • Monitoring: Maintain acceptable urine output to help decrease renal failure. Glucose infusion may be needed to prevent hypoglycemia. Avoid unnecessary esophageal instrumentation in patients with esophageal varies.
  12. Unconjugated hyperbilirubinemia
    Causes: increased bilirubin production, decreased hepatic uptake of bilirubin, or decreased conjugation
  13. Conjugated hyperbilirubinemia
    Causes: decreased canalicular transport of bilirubin, acute or chronic hepatocellular dysfunction, or obstruction of the bile ducts.
  14. Hereditary Hyperbilirubinemia
    • Gilbert's syndrome: Most common hereditary form. Glucoronosyl transferase enzyme mutation
    • Crigler-Najjar Syndrome: Hereditary unconjugated hyperbilirubinemia. 
    • Dubin-Johnson: Conjugated hyperbilirubinemia
    • Benign postoperative intrahepatic cholestasis: often following prolonged surgery
    • Progressive familial intrahepatic cholestasis:
  15. Acute Liver Failure: Info
    • Causes: viral and drug induced (most common), toxin, ischemia, acute fatty liver of pregnancy, Reye's syndrome. 
    • S/S: Prolonged PT, malaise, nausea, jaundice, altered mental status, coma. 
    • Labs: Increased aminotransferases,, hypoglycemia, respiratory alkalosis.
  16. Acute Liver failure: Anesthesia
    • Only perform surgery to correct life-threatening problems. 
    • Coagulation correction: fresh frozen plasma (all factors)
    • Low doses of volatiles or N2O.
    • IV anesthetics may have prolonged effects
    • Muscle relaxants: consider cisatracurium. 
    • Glucose to tx. hypoglycemia.
  17. Liver transplantation: Anesthesia
    • Induction can be affected by the presence of ascites compromising lung volumes and delaying gastric emptying
    • Hypoxemia and pulmonary aspiration are significant risks. 
    • N2O often avoided due to bowel distension. 
    • Stages: Dissection, anhepatic, reperfusion/neohepatic
  18. Liver transplant recipients: Anesthesia
    Chronic immunosuppression: may cause systemic HTN, anemia, thrombocytopenia, and altered drug effects
  19. Acute Cholecystitis
    • Info: obstruction of the cystic duct (gallstones/cholelithiasis) producing acute inflammation of the gallbladder. 
    • S/S: Severe pain in the mid-epigastrium radiating to the UR quadrant and may radiate to the back due to a biliary colic. 
    • Complications: Due to inflammation and necrosis of the gallbladder.
  20. Acute Cholecystitis: Anesthesia for laparoscopic cholecystectomy
    • Insufflation of the abdomen interferes with ventilation and decreases venous return&CO and increased MAP and SVR.
    • Endotracheal intubation with a cuffed tube minimizes the risk of pulmonary aspiration
    • CO2 embolism may be the cause for a CV collapse and capnography is important to recognize it.
    • Cardiac dysrhythmias may occur due to hypercarbia.
    • Opioids may cause spasm of the sphincter of Oddi (tx w/ naloxone or glucagon, possibly NTG).