Anesthetic considerations for the patient with liver disease

Hoetzel, Alexander; Ryan, Helen; Schmidt, René

doi:10.1097/aco.0b013e3283532b02

Cited by 43 publications

(46 citation statements)

References 87 publications

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“…In addition, the pharmacokinetics of phenylpiperidine opioids such as fentanyl, sufentanil, and remifentanil appear to be rarely affected by hepatic disease [15]. Moreover, the opioids fentanyl, sufentanil, and remifentanil may be the best choices in liver insufficiency cases [16]. However, because fentanyl is indeed metabolized in the liver, its pharmacokinetics may vary depending on the different stages of liver disease.…”

Section: Discussionmentioning

confidence: 99%

Risk factors for bradypnea in a historical cohort of surgical patients receiving fentanyl-based intravenous analgesia

et al. 2018

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Introduction: The use of both pulse oximetry (SpO 2 ) and respiration rate (RR) monitoring is recommended to prevent the development of respiratory deterioration, particularly after extubation and narcotic analgesic use for pain management. In this study, we investigated the factors contributing to the development of bradypnea in surgical patients receiving fentanyl-based intravenous analgesia after general anesthesia. Methods: This study involved a historical chart review of postoperative patients outside an intensive care unit setting. We divided the patients according to the data collected during the first hour postoperatively, into those developing bradypnea (RR < 8 breaths per min for > 2 min) and those with normal RR under oxygen administration. We defined oxygen desaturation as SpO 2 < 90% for > 10 s. We calculated the effect-site concentrations for fentanyl at the end of surgery and 1 h postoperatively using custom-made software based on chart records. A multivariable analysis was used to determine bradypnea-associated explanatory factors. Results: For the final analysis, we included 258 patients. We detected bradypnea in 125 patients (48%) and oxygen desaturation in 46 patients (18%). We found no difference in the effect-site fentanyl concentrations between patients with and without bradypnea. The logistic regression model revealed that liver dysfunction [odds ratio (OR), 2.918; 95% confidence interval (CI), 1.329-6.405], renal dysfunction (OR, 0.349; 95% CI, 0.128-0.955), and smoking history (OR, 0.236; 95% CI, 0.075-0.735) were independently associated with bradypnea. We found similar incidences of oxygen desaturation between the groups. Conclusions: Bradypnea was observed in 48% of postoperative patients receiving fentanyl-based intravenous analgesia under oxygen therapy. According to our results, impaired liver function associated positively, whereas smoking history associated negatively with its development. Renal dysfunction was paradoxically associated with less incidence of bradypnea.

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Section: Discussionmentioning

confidence: 99%

Risk factors for bradypnea in a historical cohort of surgical patients receiving fentanyl-based intravenous analgesia

et al. 2018

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“…It is preferable to use neuroleptics, such as haloperidol or promazine (the latter is more sedative) [138]. Severely agitated patients may require ICU hospitalization and IV propofol sedation [139,140]. Obviously, treatment of the precipitating event, ARD treatment, and nutrition and hydration are mandatory while the patient is sedated.…”

Section: Treatmentmentioning

confidence: 99%

Hepatic encephalopathy

Amodio¹

2015

Cirrhosis: A Practical Guide to Management

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“…69 Atracurium and cisatracurium are metabolized independent of the liver and are preferred in patients with liver disease. 68 …”

Section: Anesthetic Managementmentioning

confidence: 99%

“…In general, propofol is preferred to benzodiazepines as a narcotic. Among opioids, sufentanil and remifentanil are preferred 68 and oxazepam is the preferred sedative in liver insufficiency.…”

Section: Anesthetic Managementmentioning

confidence: 99%

Surgery in a Patient with Liver Disease

Rai

Nagral

2012

Journal of Clinical and Experimental Hepatology

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Surgery is often needed in patients with concurrent liver disease. The multiple physiological roles of the liver places these patients at an increased risk of morbidity and mortality. Diseases necessitating surgery like gallstones and hernia are more common in patients with cirrhosis. Assessment of severity of liver dysfunction before surgery is important and the risk benefit of the procedure needs to be carefully assessed. The disease severity may vary from mild transaminase rise to decompensated cirrhosis. Surgery should be avoided if possible in the emergency setting, in the setting of acute and alcoholic hepatitis, in a patient of cirrhosis who is child class C or has a MELD score more than 15 or any patient with significant extrahepatic organ dysfunction. In this subset of patients, all possible means to manage these patients conservatively should be attempted. Modified Child-Pugh scores and model for end-stage liver disease (MELD) scores can predict mortality after surgery fairly reliably including nonhepatic abdominal surgery. Pre-operative optimization would include control of ascites, correction of electrolyte imbalance, improving renal dysfunction, cardiorespiratory assessment, and correction of coagulation. Tests of global hemostasis like thromboelastography and thrombin generation time may be more predictive of the risk of bleeding compared with the conventional tests of coagulation in patients with cirrhosis. Correction of international normalized ratio with fresh frozen plasma does not necessarily mean reduction of bleeding risk and may increase the risk of volume overload and lung injury. International normalized ratio liver may better reflect the coagulation status. Recombinant factor VIIa in patients with cirrhosis needing surgery needs further study. Intra-operatively, safe anesthetic agents like isoflurane and propofol with avoidance of hypotension are advised. In general, nonsteroidal anti-inflammatory drug (NSAIDs) and benzodiazepines should not be used. Intra-abdominal surgery in a patient with cirrhosis becomes more challenging in the presence of ascites, portal hypertension, and hepatomegaly. Uncontrolled hemorrhage due to coagulopathy and portal hypertension, sepsis, renal dysfunction, and worsening of liver failure contribute to the morbidity and mortality in these patients. Steps to reduce ascitic leaks and infections need to be taken. Any patient with cirrhosis undergoing major surgery should be referred to a specialist center with experience in managing liver disease. ( J CLIN EXP HEPATOL 2012;2:238-246)

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Anesthetic considerations for the patient with liver disease

Cited by 43 publications

References 87 publications

Risk factors for bradypnea in a historical cohort of surgical patients receiving fentanyl-based intravenous analgesia

Risk factors for bradypnea in a historical cohort of surgical patients receiving fentanyl-based intravenous analgesia

Hepatic encephalopathy

Surgery in a Patient with Liver Disease

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