Professional Documents
Culture Documents
EVERYDAY CHALLENGES IN
CLINICAL PRACTICE
PSH 2017
Objectives
Metabolism of medications
Metabolism of medications
Coagulopathy
Ascites
Hepatic encephalopathy
• Potential causes:
• Intravascular volume depletion
• Nephrotoxicity
• ATN
• Hepatorenal syndrome (HRS)
PSH 2017
Pulmonary complications
• Ascites and hepatic hydrothorax
• Increased risk of aspiration
• Pneumonia
• ARDS
• Ventilation dependence
• Hepatopulmonary syndrome:
Triad of liver disease, increased AA gradient and
intrapulmonary shunting
PSH 2017
EFFECTS OF ANESTHESIA AND
SURGERY ON THE LIVER
• Depends upon:
– Type of anesthesia used
– specific surgical procedures
– severity of liver disease.
– Perioperative events
hypotension
sepsis
Administration of hepatotoxic drugs
PSH 2017
ESTIMATING SURGICAL RISK
Acute hepatitis
Alcoholic hepatitis
Abstinence from alcohol for at least 12 weeks
improves hepatic inflammation and hyperbilirubinemia
Reassess after 12 weeks
Acute liver failure
HARVILLE DD, SUMMERSKILL WH. Surgery in acute hepatitis. Causes and effects. JAMA 1963; 184:257.
Greenwood SM, Leffler CT, Minkowitz S. The increased mortality rate of open liver biopsy in alcoholic
hepatitis. Surg Gynecol Obstet 1972; 134:600.
Child-Turcotte-Pugh score
PSH 2017
ASA Classification
PSH 2017
PSH 2017
PSH 2017
• Obstructive jaundice —
• Increased risk of perioperative complications
Infections
stress ulceration
DIC
wound dehiscence
renal failure
PSH 2017
• Cardiac surgery —
Cardiac surgery is associated with increased mortality in
patients with cirrhosis compared to other surgical
procedures
PSH 2017
• Hepatic resection —
• RESIDUAL VOLUME NEEDED
• Normal Liver 25%
• Cirrhotic liver 40%
• Risk factors for hepatic decompensation
CTP
MELD
BILIRUBIN
PT
Portal Hypertension
PSH 2017
• Trauma —
• Trauma patients found to have cirrhosis at laparotomy are at
increased risk for morbidity and mortality.
• In one study, the overall mortality rate was 45 percent,
significantly higher than of a matched control population
(24 percent)
PSH 2017
• Abdominal surgery —
In patients undergoing cholecystectomy, a laparoscopic
approach is associated with lower mortality rates than an
open approach and can be performed in patients with CP
class A and B cirrhosis and MELD scores up to 13
PSH 2017
• Autoimmune hepatitis —
– Elective surgery is usually well tolerated in patients with
autoimmune hepatitis who have compensated liver disease.
– Perioperative "stress" doses of hydrocortisone should be given to
patients taking prednisone.
PSH 2017
• Hemochromatosis —
– Evaluation for complications
Diabetes
Cardiomyopathy
PSH 2017
• Wilson disease —
Patients with Wilson disease who have neuropsychiatric
involvement may not be able to provide informed consent.
Surgery can precipitate or aggravate neurologic symptoms
D-penicillamine interferes with the crosslinking of collagen
and may impair wound healing
the dose should be decreased prior to surgery and during the
first one to two postoperative weeks
OPTIMIZING MEDICAL THERAPY
PSH 2017
COAGULOPATHY