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The liver is the site of synthesis of all clotting factors except



CV function in patients with cirrhosis

  1. Hyperdynamic circulation
    • High CO and Low SVR
  2. Possible cardiomyopathy
  3. Decreased response to catecholamines
  4. Increased flow to splanchnic, pulm, muscular, cutaneous beds
  5. Decreased hepatic flow
  6. Portal HTN
  7. Arterial hypoxemia


S/S of cirrhosis

  • Fatigue /malaise
  • Anorexia/ weakness
  • Nausea/ vomiting 
  • Abdominal pain
  • Jaundice /spider nevi
  • Hypoalbuminemia
  • Coagulation disorders
  • Endocrine disorders
  • Hepatic encephalopathy
  • Gastroesophageal variceal
  • Hepatomegaly /ascites


Many alcoholics can get cardiomyopathy. How does this affect your anesthetic?

Don't give anything that depressed the myocardium


How do the majority of cirrhosis patients die during abdominal surgery?

60% die from bleeding


Coagulation in Cirrhosis

Treat bleeding with FFP, Vitamin K, Platelets

Cirrhosis patients will have: 

  1. Prolonged PT/INR
  2. Vit K deficiency
  3. factors II, V, VII, IX, X deficiency
  4. Thrombocytopenia

(Bleeding accounts for 60% of deaths in abdominal surgery →surgery contraindicated if Platelets are low )



Pre-op considerations in cirrhosis

  1. Treat as full stomach →RSI
  2. Low albumin → decrease drug doses
  3. Ascites → fluid status
  4. Cardiomyopathy
  5. PaO2 60-70 (R→L pulm shunt)
  6. Hypoglycemia
  7. Pneumonia
  8. Encephalopathy
  9. Hepatorenal syndrome


monitoring for cirrhosis patients

  1. CVP, A-line, +/- PA
  2. UO → foley
  3. Blood glucose
  4. AVOID esophageal temp probe


Why are cirrhosis patients considered full stomachs?

  1. Alcohol use weakens the lower esophageal sphincter
  2. ascites 


Liver patients tend to be (hyper/hypo)glycemic

  • Hypoglycemic.
    • Give fluids with glucose
  • Pts are hypoglycemic d/t decreased hepatic gluconeogenesis


How should we maintain anesthesia for the patient with cirrhosis?

IA at 1/2 MAC with N2O and opioids


In cirrhosis, we need a (higher/lower) dose of NMRs and why?

Need higher dose because Vd will be increased


What NMBs are best for cirrhosis

  • Mivacurium
  • atracurium
  • cisatracurium*
  • (the ones metabolized in blood)
  • Sux is apparently ok too


Reasons why liver patients are at risk for morbidities post-op

  • Pneumonia
  • Bleeding
  • Sepsis
  • Poor wound healing
  • Liver dysfunction
  • DT’s


Other comorbidities that alcoholics may have

  • Hypothermia
  • alcoholic poluneuropathy
  • Wernicke-Korsakoff syndrome
  • Pernicious anemia


Considerations for Maintenance of anesthesia in cirrhosis patients


  1. Balanced technique: 
    • Combine Volitile anesthetics (1/2 MAC), N2O and opioids.
  2. Manitain hepatic blood flow
    • Sevo, Iso and Des are all safe to use
    • MUST maintain an adequate BP →hypotension will decrease oxygen delivery to the hepatoytes
  3.  Use NMBs that are metabolized in the blood
    • mivacurium, atracurioum, cis-atratrcurium, sux
    • Will also need larger doses → d/t larger volume of distribution, but also the doses will last longer
  4. Don't give anything that will depress the heart!
  5. Patients will have low protein binding
  6. Bleeding risk
  7. Considered full stomachs
    • poor lower esophageal sphincter tone
  8. Give fluids that contain glucose → often they become hypoglycemic


This enzyme is deficient in porphyria

ALA synthetase


S/S of porphyria attack

  • abd pain
  • N/V
  • ANS instability (HTN and tachycardia)
  • electorlyte (Na, K, MG) disturbances
  • neuro psych manifestations
  • weakness
    • can progress to quadriparesis and respiratory failure


Regional anesthesia and porhyria

  1. AVOID During an acute exacerbation
  2. otherwise no absolute contraindications
  3. Pre anesthetic neuro eval
  4. Keep in mind ANS blockade may lead to cardiovascular instibility (especially with hypovolemia)


Why do patients have hyperdynamic circulation with liver disease?

  • Accumulation of vasodilating compounds like prostaglandins and interleukins
  • Reduced blood viscosity may also play a role.


Any IAs that decrease hepatic BF will increase serum concentrations of

Alpha-GST (Glutathione S-transferases)


Blood volume in liver disease

  • Decreased in
    • central circulation
  • but increase in
    • splanchnic, pulmonary, muscle, and cutaneous corcualtion.


GA Considerations in porphyria

  1. Use short acting agents
  2. Monitor for instability
  3. Induction
    • Propofol, ketamine → these are ok to use in porphyria
    • NO ETOMIDATE → trigger 
  4. Maintenance
    • Nitrous, inhaled anesthetics, opioids, NDMR
  5. CP bypass  is a stress  → will need ICU after and VERY good post op management!


Is cimetidine good or bad in porphyria?


It decreases heme consumption and decreases ALA synthetase activity


These meds can be given to treat porphyria

Hematin 3-4 mg/kg IV, somatostatin, plasmapheresis




  1. Consider volume & electrolyte replacement
  2. RSI with cricoid pressure, cuffed tube
  3. Reverse tburg
  4. Mechanical ventilation
  5. Judicious use of opioids


Cholecystectomy and opioids

  • Sphincter of Oddi spasm occurs in 3% of the population
  • Antagonize spasm with
    • Naloxone (maybe not the best idea)
    • glucagon
    • NTG


Volatile anesthetics and hepatic dysfunctions

  • VA produce a self-limiting post-op liver dysfunction
    • transient increase in alpha-GST
  • Halothane hepatitis
    • Immune mediated 1 in 10,000-30,000
    • Only Sevo does not metabolize into trifluoroacetylated compounds


What would you do if a patient has post-op hepatic dysfunction

 Multi-factorial analysis

  1. Review all drugs administered
  2. Check for sepsis
  3. Check bilirubin 
  4. Rule out occult hematomas → hyperbilirubinemia
  5. Review peri-operative record for
    • hypotension
    • hypoventilation
    • hypoxemia
    • hypercarbia
    • hypovolemia


What is hepatitis

Inflammation of the liver parenchyma d/t 

  1. Viral
  2. Autoimmune
  3. Drug-Induced


  • usually self-limiting and most often viral but can be caused by drugs/toxins


  • Hepatic inflammation >6 months 
  • Cirrhosis, hepatocellular carcinoma or liver failure (ETOH/HCV/HBV/Autoimmune)

Symptoms may be minimal (malaise/jaundice) to severe with compromise to multiple organ systems