Anesthesia for Surgical Procedures in Cirrhotic Patients Other than Liver Transplantation: Management, Concerns, and Pitfalls

Abstract

In patients with cirrhosis, the perioperative risk of anesthesia is invariably linked to the severity of hepatic dysfunction and the nature of the procedure, rather than the selection of anesthetic. The MELD (Model for End-stage Liver Disease) score has predictive value for perioperative risk, with MELD scores of 25 or more associated with 1-month mortality of 50%. Surgical procedures near the liver are associated with reductions in hepatic blood flow, which can lead to decompensation and hepatic failure. Other conditions associated with decompensation include preoperative infection, higher ASA (American Society of Anesthesiologists) physical status score, and surgery on the respiratory system. Preoperative medical management should focus on treating infection, optimizing blood volume and renal status, and minimizing ascites and encephalopathy. However, specific goal-directed targets have not been shown to improve outcomes. Routine administration of prophylactic plasma in an attempt to correct INR abnormalities should be avoided, as volume loading is associated with increases in portal pressure that may worsen bleeding. Unique conditions associated with cirrhosis – hepatopulmonary syndrome, portopulmonary hypertension, and hepatorenal syndrome – also increase perioperative risk. Patients with an advanced disease benefit from liver transplantation prior to elective surgery. When such patients require emergency surgery they should be evaluated for minimally invasive and less extensive surgical alternatives. The effects of hepatic dysfunction on perioperative sedation and anesthetic selection are described, as is the anesthetic management of hepatic resection.