RT Book, Section
A1 Taylor, Norman
A1 Pierce, Eric T.
A2 Longnecker, David E.
A2 Mackey, Sean C.
A2 Newman, Mark F.
A2 Sandberg, Warren S.
A2 Zapol, Warren M.
SR Print(0)
ID 1144113196
T1 The Patient With Hepatic Disease
T2 Anesthesiology, 3e
YR 2017
FD 2017
PB McGraw-Hill Education
PP New York, NY
SN 9780071848817
LK accessanesthesiology.mhmedical.com/content.aspx?aid=1144113196
RD 2024/04/16
AB KEY  POINTSThe  Child-Turcotte-Pugh  and  MELD  scoring  systems  predict  the  risk  of  surgery  for  patients  with  liver  disease.  These  systems  require  knowledge  of  the  patient’s  international  normalized  ratio  (INR),  plasma  bilirubin  level,  plasma  albumin  level,  degree  of  encephalopathy,  and  volume  of  ascites.The  leading  causes  of  perioperative  death  or  complications  for  patients  with  advanced  liver  disease  include  hemorrhage  secondary  to  coagulopathy;  elevated  intracranial  pressure;  sepsis  secondary  to  peritonitis  or  pneumonitis;  an  ascites  fluid  leak  at  the  site  of  surgical  incision;  and  acute  renal  failure  secondary  to  hemodynamic  instability  or  hepatorenal  syndrome.Serious  but  rare  complications  of  chronic  liver  disease  include  the  hepatorenal  syndrome,  the  hepatopulmonary  syndrome,  and  portopulmonary  hypertension.  These  may  resolve  following  liver  transplantation.Most  forms  of  chronic  liver  disease  lead  to  cirrhosis,  a  histologic  diagnosis  that  is  characterized  by  fibronodular  hyperplasia  leading  to  compression  and  obstruction  of  sinusoidal  capillaries  and  bile  canaliculi.  These  histologic  findings  account  for  the  development  of  portal  hypertension  that  is  manifested  by  ascites,  esophageal  varices,  and  hypersplenism.Inflammatory  cellular  mechanisms  play  a  role  in  the  development  of  most  forms  of  liver  disease.  Inflammatory  mechanisms  initiate  hepatocellular  dysfunction,  hepatocyte  necrosis,  and  portal  fibrosis.Laboratory  testing  for  the  evaluation  of  liver  disease  includes  tests  of  synthetic  function  (INR,  serum  albumin,  and  other  serum  proteins);  excretory  function  (plasma  bilirubin  levels);  and  metabolic  function  (blood  glucose,  cholesterol,  lipoprotein  levels),  as  well  as  evaluation  of  bile  duct  obstruction  (plasma  alkaline  phosphatase)  and  hepatocellular  injury  (plasma  aspartate  aminotransferase  and  alanine  aminotransferase  levels).  Ultrasonography,  computed  tomography,  and  magnetic  resonance  imaging  contribute  to  establishing  an  anatomic  cause  of  liver  dysfunction.Transmission  of  viral  infection  (eg,  viral  hepatitis)  by  means  of  blood  product  administration  has  become  rare  because  of  routine  immunologic  and  molecular  screening  of  donors  for  various  infectious  diseases.  Transmission  to  health  care  workers  continues  to  be  a  hazard  because  of  the  lack  of  immunization  against  hepatitis  C.  Health  care  workers  who  are  carriers  of  hepatitis  B  or  C  should  limit  the  risk  of  transmitting  their  disease  to  their  patients.Nonalcoholic  fatty  liver  disease  is  emerging  as  a  leading  cause  of  liver  disease  in  the  United  States.  Its  prevalence  is  tied  to  the  frequency  of  type  2  diabetes  and  the  increasing  problem  of  morbid  obesity.Preoperative  attention  to  the  control  of  ascites,  correction  of  coagulopathy,  control  of  encephalopathy,  optimization  of  renal  and  pulmonary  function,  and  reduction  of  the  risk  of  sepsis  will  decrease  the  risk  of  postoperative  complications  and  improve  survival  rates  following  surgery  in  patients  with  liver  disease.Anesthesia-related  drugs  such  as  sedatives  and  vasopressors  should  be  used  with  increased  caution  in  patients  with  liver  disease.  Benzodiazepines  may  unmask  a  subclinical  encephalopathy.  Vasopressors  may  decrease  total  hepatic  blood  flow,  inducing  ischemia  and  potential  acute  liver  failure.