Anaesthesia to patiens with liver disease or a liver transplant
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A presentation by Anna Januszkiewicz at the 2017 meeting of the Scandinavian Society of Anaestesiology and Intensive Care Medicine. All available content from SSAI2017: https://scanfoam.org/ssai2017/ Delivered in collaboration between scanFOAM, SSAI & SFAI.
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Anaesthesia to patiens with liver disease or a liver transplant
- 1. Anaesthesia for patients with liver disease Anna Januszkiewicz, MD, PhD PMI, Karolinska University Hospital, Huddinge
- 2. • Liver diseases and pathology of cirrhosis • Extrahepatic manifestations of liver disease • Preoperative evaluation and risk assessment • Drugs • Intraoperative considerations • Postoperative care
- 3. Liver function • Bile production • Metabolic (carbohydrates, proteins, fat) • Synthetic (albumin, coagulation factors) • Storage (glycogen, fatty acids, vitamins and minerals) • Detoxification (ammonium, drugs, alcohol) • Immunological (Kupffer cells)
- 4. Causes of liver disease Chronic • viral hepatitis • autoimmune hepatitis • alcoholic liver disease • NAFLD/NASH • cholestatic (PSC, PBC) • metabolic diseases (Wilson, heamochromatosis, α-1 antitrypsin deficiency) • drugs, toxins Acute • drugs (paracetamol) • viral hepatitis • idiopathic
- 5. Liver cirrhosis • Chronic inflammation and cytokines release • Activation of stellate cells and transformation to myofibroblasts • Generation of collagen ultimately leading to liver fibrosis, a precursor of cirrhosis • Progression of parenchymal scarring with nodular structure The final common pathological result of liver damage arising from many types of chronic liver diseases. Zhou W-C et al, 2014 Henderson NC, Iredale JP, 2007
- 6. • Liver diseases and pathology of cirrhosis • Extrahepatic manifestations of liver disease • Preoperative evaluation and risk assessment • Drugs • Intraoperative considerations • Postoperative care
- 7. Extrahepatic manifestations of liver disease • gastrointestinal • cardiovascular • respiratory • coagulation • renal • metabolic/electrolyte/acid-base • CNS
- 8. Gastrointestinal effects • Portal hypertension - pressure >10 mm Hg - development of collateral venous circulation • Splenomegaly (sequestration of platelets) • Ascites (increased intra-abdominal pressure) • GI bleeding from oesophageal varices • Delayed gastric emptying
- 9. Cardiovascular effects Splanchnic arterial vasodilatation Splanchnic blood pooling Decreased arterial blood volume Liver cirrhosis Arterial hypotension
- 10. Cardiovascular effects Arterial hypotension Increased HR and SV Increased CO Hyperdynamic circulation Decreased SVR Neurohumoral response Sympathetic nervous system Renin-Angiotensin-Aldosterone ADH Natrium and water retention Renal vasoconstriction
- 11. Cardiovascular effects Hyperdynamic circulation • high CO • low SVR • hypotension • tachycardia Cirrhotic cardiomyopathy • systolic dysfunction ca 10% o decreased contractility o diminished stress response • diastolic dysfunction ca 60% o assessed by echo o present at rest • QT-interval prolongation • chronotropic incompetence • increased myocardial mass • increased BNP and pro-BNP • increased troponin I Bolognesi et al, WJG, 2014 Ruiz-de- Árbol, Serradilla, WJG, 2015 Liu et al, Liver Transpl, 2017
- 12. Zardi et al, JACC 2010
- 13. Respiratory effects • pleural effusion • reduced FRC due to ascites • hepatopulmonary syndrome (HPS) due to intrapulmonary arteriovenous shunting • portopulmonary hypertension – increased PVR, normal PCWP Krowka MJ, Clin Liver Dis, 2011
- 15. Coagulation Lisman T, Porte R, 2010
- 16. Coagulation • Bleeding risk - decreased synthesis of coagulation factors (II, VII, IX, X) - decreased synthesis of fibrinogen - vit. K deficiency - thrombocytopenia/thrombocytopathy - fibrinolysis • Hypercoagulation - decreased synthesis of Protein C, Protein S, antithrombin - decreased synthesis of plasminogen - increased activity of VWF • Tromboelastography (TEG)/Tromboelastometry (ROTEM)
- 17. Renal effects - AKI Causes of AKI in cirrhotic patients: • hypovolemia • renal/parenchymal disorders (tubular necrosis, interstitial nephritis, glomerular disease • hepatorenal syndrome (HRS) 70% of cirrhotic patients have renal dysfunction without structural changes. HRS • functional renal defect • caused by renal hypoperfusion due to decreased SVR • treatment - vasopressin analogues (terlipressin, glypressin) Karvellas et al, Crit Care Clin, 2015 Warner et al, J Investig Med, 2011
- 18. Metabolic/electrolyte/acid-base effects • hypoglycemia due to depletion of glycogen stores • hypoalbuminemia • malnutrition • hyponatremia • hypo-/hyperkalemia • respiratory alkalosis • metabolic acidosis (decompensated liver cirrhos, critical illness) Musso CG et al, Int Urol Nephrol, 2017 Bernhard S et al, J Hepatol, 2017
- 19. CNS Shawcross et al, Eur J Gastroeneterol Hepatol, 2016 Wijdicks EFM, NEJM, 2016 • decreased clearance of neurotoxins (ammonia) • varying clinical symptoms • restrictive use of sedatives!
- 20. • Liver diseases and pathology of cirrhosis • Extrahepatic manifestations of liver disease • Preoperative evaluation and risk assessment • Drugs • Intraoperative considerations • Postoperative care
- 21. Preoperative evaluation • Severity of liver dysfunction • Co-existing morbidity • Type of surgery • Monitoring • Postoperative facilities Lopez-Delgado et al, World J Gastroeneterol, 2016
- 22. Preoperative evaluation • History (dyspnoea, effort tolerance, bleeding, presence of esophageal varices, encephalopathy) • Physical examination (orientation, saturation, pleural effusion, pulse, blood pressure, ascites, bruising, malnutrition) • Investigations o blood count (anemia, infection) o coagulation (INR, platelets, fibrinogen) and ROTEM/TEG o renal function (creatinine, urea, GFR) o liver function (bilirubin, enzymes, albumin) o blood gas, electrolytes, serum glucose o ECG/exercise ECG o echocardiography/stress echo o chest X-ray Vaja et al, BJA, 2010
- 23. Risk assessment Scoring systems • CTP score – predict mortality in patients with liver disease undergoing surgery • MELD score – used to predict mortality for patients on waiting list for Ltx MELD – formula based on serum creatinin, bilirubin and INR
- 24. Risk assessment Neeff et al, Surgery, 2014 Survival after general surgery in 180 patients with liver cirrhosis by preoperative CTP or MELD classification
- 25. Risk assessment Predictors of poor outcome: • liver function • co-morbidities • blood transfusions • emergency surgery/major • age Preoperative optimization: • minimizing preexisting encephalopathy • correction of coagulopathy • treatment of infections • correction of electrolyte imbalance • thoracentesis Elective surgery should be postponed: • acute viral/alcoholic hepatitis • acute liver failure • patients with CTP C or MELD>15 Neeff et al, Surgery, 2014 Hoetzel et al, Curr Opin Anesthesiol, 2012 Friedman LS, Trans Am Clin Climatol Ass, 2010
- 26. • Liver diseases and pathology of cirrhosis • Extrahepatic manifestations of liver disease • Preoperative evaluation and risk assessment • Drugs • Intraoperative considerations • Postoperative care
- 27. Drugs Altered drug pharmacokinetics • increased volume of distribution • increased fraction of active drugs due to decreased synthesis of albumin • reduced synthesis of some enzymes (pseudocholinesterase) • decreased clearance Sedatives • propofol, – safe • thiopental, dexmetomidine – dose reduction • benzodiazepines – should be avoided, alt. dose reduction by 50% • ketamine - safe Opioids • fentanyl – consider dose reduction in repeated doses • remifentanil – safe • morphine, alphentanil – prolonged half-lifes Mcclain RL et al, Curr Clin Pharmacol, 2015
- 28. Drugs Neuromuscular blocking agents • atracurium, cis-atracurium – safe • succinylcholine – dose reduction (due to pseudocholinesterase defieciency) • vecuronium/rocuronium – dose reduction?, not recommended due to prolonged duration of action, but sugammadex reverse effectively Volatile anesthetics • sevoflurane, isoflurane, desflurane – safe • halothane – not recommended Mcclain RL et al, Curr Clin Pharmacol, 2015 Fujita et al, Acta Anaesthesiol Taiwan, 2014
- 29. • Liver diseases and pathology of cirrhosis • Extrahepatic manifestations of liver disease • Preoperative evaluation and risk assessment • Drugs • Intraoperative considerations • Postoperative care
- 30. Intraoperative considerations Monitoring – matching the severity of liver disease and extense of surgery • ECG, pulse oximetry, end-tidal CO2, peripheral nerve stimulator, temperature, urine output, bispectral index • invasive BP • large-bore i.v. access • CVC, consider PA-catheter • TEE • ROTEM/TEG Risk for complications due to severe liver disease • aspiration (ascites, delayed gastric emptying) • hypoxemia (ascites, pleural effusion, HPS) • hypotension (hypovolemia) • bleeding (oesophageal varices, coagulopathy) • oliguria (HRS) • hypoglycemia Hoetzel et al, Curr Opin Anesthesiol, 2012 Starczewska et al, Curr Opin Anesthesiol, 2017
- 31. Intraoperative considerations Goal – maintenance of adequate hepatic blood flow and oxygen delivery to prevent decompensation • optimal fluid therapy (guided by TEE or PA-catheter) • vasopressors • bleeding – assessment of clinical situation, lab and ROTEM/TEG • avoid hypothermia Hoetzel et al, Curr Opin Anesthesiol, 2012 Starczewska et al, Curr Opin Anesthesiol, 2017
- 32. • Liver diseases and pathology of cirrhosis • Extrahepatic manifestations of liver disease • Preoperative evaluation and risk assessment • Drugs • Intraoperative considerations • Postoperative care
- 33. Postoperative care Postoperative pain management • TAP blocks, local infiltrations, PainBuster • epidural analgesia – caution • NSAIDs – contraindicated (risk of GI bleeding, platelet dysfunction, nephrotoxicity) • paracetamol – dose reduction • opioids – dose reduction Monitoring • liver function (clinically and biochemically) for signs of decompensation • CNS • renal • coagulation • infections • electrolytes, serum glucose, ABG Lopez-Delgado et al, WJG, 2016 Vaja et al, BJA, 2010 Hayward K et al, Brit J Clin Pharmaco, 2016
- 34. Anaesthetic management in liver transplanted patients • Well functioning graft – treat patients as ones with normal liver function • Graft dysfunction – treat patients as ones with liver disease Do not forget immunosuppression! anna.januszkiewicz@sll.se
- 35. 35
- 36. Risk assessment Banghui et al, J Hepatol, 2012