- Patients with acute hepatitis should have
any elective surgery postponed until the acute hepatitis has resolved,
as indicated by normalization of liver tests. Studies indicate increased
perioperative morbidity (12%) and mortality (up to 10% with
laparotomy) during acute viral hepatitis.
- Isoflurane is the volatile agent of choice because
it has the least effect on hepatic blood flow. Factors known to
reduce hepatic blood flow, such as hypotension, excessive sympathetic
activation, and high mean airway pressures during controlled ventilation,
should be avoided.
- In evaluating patients for chronic hepatitis,
laboratory test results may show only a mild elevation in serum
aminotransferase activity and often correlate poorly with disease
- Approximately 10% of patients with cirrhosis
also develop at least one episode of spontaneous bacterial peritonitis,
and some may eventually develop hepatocellular carcinoma.
- In patients with cirrhosis, massive bleeding
from gastroesophageal varices is a major cause of morbidity and
- Cirrhosis is typically characterized by a hyperdynamic
- Hypoxemia is frequently present and is due to
right-to-left shunting (up to 40% of cardiac output).
- The hepatorenal syndrome is a functional renal
defect in patients with cirrhosis that usually follows gastrointestinal
bleeding, aggressive diuresis, sepsis, or major surgery. It is characterized
by progressive oliguria with avid sodium retention, azotemia, intractable
ascites, and a very high mortality rate.
- Factors known to precipitate hepatic encephalopathy in patients
with cirrhosis include gastrointestinal bleeding, increased dietary
protein intake, hypokalemic alkalosis (from vomiting or diuresis),
infections, and worsening liver function.
- Following the removal of large amounts of ascitic
fluid, intravenous colloid fluid replacement is often necessary
to prevent profound hypotension and renal shutdown.
The prevalence of liver disease is increasing in the United States.
Cirrhosis, the terminal pathology in a majority of liver diseases,
appears to have a general incidence in some autopsy series as high
as 5%. It is a major cause of death of men in their fourth
and fifth decades, and mortality rates are increasing. Ten percent
of the patients with liver disease undergo operative procedures during
the final 2 years of their lives. The liver has remarkable functional
reserve, and clinical manifestations of hepatic disease are often
absent until extensive damage has occurred. Consequently, when these
marginal patients with little reserve come to the operating room,
effects from anesthetics and surgery (see Chapter
34) can precipitate further hepatic decompensation, leading
to overt hepatic failure.
This chapter discusses the anesthetic management of patients
with known liver disease. With some important exceptions, the anesthetic
considerations tend to be similar in both acute and chronic liver
disease. Although patients with cholelithiasis often have minimal
hepatic impairment, the effects of anesthesia on the biliary system
also require comment.
Acute hepatitis is usually the result of viral infection, a drug
reaction, or exposure to a hepatotoxin. The illness represents acute
hepatocellular injury with variable amounts of cell necrosis. Clinical
manifestations generally depend both on the severity of the inflammatory