Anesthetic Considerations in Patients With Hepatic Failure

Abstract

A 48-year-old man with a history of Laennec's cirrhosis (Childs class B) and hepatitis C diagnosed 3 years previously, and with a history of thrombocytopenia and moderate/severe coagulopathy, presented for dental rehabilitation/tooth extraction secondary to dental caries. The patient had no active bleeding issues at the time of presentation. The patient had a history of ingestion of 1 pint of whiskey and a 12-pack of beer everyday for 20 years, although he stated he quit 2 years ago. He also had a history of smoking cigarettes (½ pack per day for 22 years) and was still actively smoking. He was taking regular medications of vitamin B12, 5 mg hydrocodone/500-mg acetaminophen tablets everyday, and esomeprazole (Nexium) for severe gastroesophageal reflux disease. The patient had other medical history of diverticulitis and had undergone colonoscopy with negative results. He had undergone lumbar surgery and facial surgery in the past with no complications noted. On initial presentation, the patient had known coagulopathy and platelet dysfunction. Laboratory values were obtained preoperatively and revealed mild hepatocellular damage (aspartate transaminase 110U/L, alanine transaminase 39U/L), synthetic dysfunction (bilirubin 2.2 mg/dL), mild hyperglycemia (133 mg/dL), significant coagulopathy (prothrombin time [PT] 21.2 seconds [international normalized ratio 1.8], partial prothrombin time [PTT] 32.7 seconds), and suspected thrombocytopenia. Platelet count was attempted on each of the different blood draws but was unable to be completed secondary to platelet clumping in each of the specimens. However, remarks by the laboratory indicated the numbers of platelets were judged to be decreased from normal levels based on slide analysis. This assessment appeared congruent with the patient's known coagulopathy.With the patient's known history, a type and cross was obtained preoperatively and the patient was prophylactically transfused with a 6 pack of platelets before being taken to the operating room (OR). Once in the OR, standard monitors, including oscillometric blood pressure cuff, finger probe pulse oximetry, and 5-lead electrocardiogram, were attached. The 45

Perioperative management of liver surgery—review on pathophysiology of liver disease and liver failure

“…It should be kept in mind that increased values in so called liver function tests (LFT) like alanine aminotransferase (ALT) or aspartate aminotransferase (AST) mainly provide information regarding hepatocellular integrity rather than making statements about functionality [ 26 ]. As albumin and most coagulation factors are synthesised by the liver, they reflect liver function more precisely [ 36 ].…”

Palliation and Liver Failure: Palliative Medications Dosage Guidelines

“…Also decreased serum albumin and changes in body water, such as increasing ascites, will change the volume of distribution of many drugs. 1 In liver failure, sedating drugs such as midazolam, a benzodiazepine, may have a greater effect, due to the presence of un-metabolised toxins, cerebral oedema, increased sensitivity to the drugs, stimulation of the gamma-aminobutyric (GABA) receptors and reduced cerebral blood flow. Whilst the various mechanisms are not fully understood, disruption of the blood brain barrier may also be part of the process.…”

“…Whilst the various mechanisms are not fully understood, disruption of the blood brain barrier may also be part of the process. 1,2 Palliative care in patients with liver failure can be a pharmacologic challenge and information on how to alter drug regimes to palliate symptoms can be difficult to find. Searches of available literature has revealed no directly relevant review articles or summaries either in the palliaitve care or general medical journals..…”