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Chapter 35

• 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 severity.
• 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 mortality.
• Cirrhosis is typically characterized by a hyperdynamic circulatory state.
• 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

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 reaction ...

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