Liver Part 1A

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Anesthesia for the patient with liver disease:

Anesthesia for the patient with liver disease

Hepatitis:

Hepatitis Acute and Chronic Viral- Type A, B, C, D, E Chronic may follow acute viral hepatitis Hepatic disease following EBV, CMV Drug or toxin induced

Viral:

Viral All are similar Infections range from asymptomatic to jaundiced or flu like symptoms Types determined by serologic testing May require liver bx

Symptoms:

S ymptoms Dark urine Nausea Fatigue Anorexia Abdominal discomfort Fever Emesis Pruritis Light colored stool

Drug Induced Hepatitis:

Drug Induced Hepatitis Can be due to drug reactions from: analgesics anticonvulsants volatile anesthetics antibiotics antihypertensives tranquilizers

Acetaminophen overdose:

Acetaminophen overdose Causes profound hepatocellular necrosis Hepatic glutathione typically conjugates toxic metabolites High doses of acetaminophen deplete stores of hepatic glutathione and toxicity increases and destroys liver cells N acetylcysteine may decrease the toxicity ETOH may decrease hepatic glutathione and cause toxicity with standard doses

Volatile anesthetics:

Volatile anesthetics May produce mild postop liver dysfunction Caused by anesthetic induced decrease in hepatic oxygen delivery relative to demand Any anesthetic that decreases hepatic flow may interfere with hepatic oxygenation α-glutathione S- tranferase (α-GST) , a sensitive marker of hepatocellular damage Levels increase transiently after volatile anesthetics

Immune mediated hepatoxicity associated with volatile anesthetics:

Immune mediated hepatoxicity associated with volatile anesthetics Rare, life threatening hepatic dysfunction following volatile anesthetic-esp. halothane Thought to be auto-immune response in genetically suseptible patients Patients with this syndrome have elevated IgG antibodies Trifluoroacetyl halide metabolite of halothane effect microsomal proteins on surface of hepatocytes A highly specific anti- trifluoroacetyl antibody test confirms diagnosis as they do not appear in other liver disease 1:10,000 to 1:30,000 adults having had halothane

Volatile agents:

Volatile agents Ethrane , isoflurane , and desflurane may form trifluoroacetyl metabolites Degree of metabolism is much less, therefore much less likely to occur A patient with genetic predisposition could be sensitized by halothane, then have hepatic dysfunction following a different volatile agent Sevo does not undergo trifluoroacetyl metabolism

Chronic hepatitis:

Chronic hepatitis Encompasses a group of diseases Long term elevation of liver chemistries (greater than 6 months) Evidence of hepatocellular inflammation with liver bx Autoimmune hepatitis, HBV with or without HDV, HCV, drug induced hepatitis, Wilsons disease,α1 antitrypsin defiency , or primary biliary cirrhosis, or primary sclerosing cholangits

Signs and symptoms:

Signs and symptoms Range from mild increase in aminotransferace to rapid progression to fulminant hepatic failure Most common symptoms are fatigue,malaise,mild abdominal pain May have arthralgia, arthritis,glomerulonephritis , rash, amenorrhea, thyroiditis

Labs:

Labs Increased liver enzymes May or may not have elevated bilirubin levels Viral hepatitis causes increase gamma globulin levels Decreased serum albumin Prolonged prothrombin times Hepatomegaly w/ wo splenomegaly

Cirrhosis:

Cirrhosis Typically the result of chronic etoh or chronic HBV, HCV Scarring of the liver causes regenerating nodules to form Liver bx establishes definitive dx Bx in pts on if INR is no more than 1.5 and PT no longer than 10 secs over normal, plts higher than 50,000 UGI endoscopy confirms varices

Signs and Symptoms:

Signs and Symptoms Fatigue and malaise Palmer erythema Spider nevi Gynecomastia Testicular atrophy Evidence of portal htn

Portal htn:

Portal htn Fibrotic changes increase resistance to hepatic flow through the portal vein Liver is enlarged with left lobe palpable below xyphoid process Decreased serum albumin and prolonged PT are typical Increased liver enzymes ( alkPtase,aminotransferases )

Complications of liver cirrhosis:

Complications of liver cirrhosis Portal vein htn Varices Ascites Hyperdynamic circulation Cardiomyopathy Anemia coagulopathy

complications:

complications Arterial hypoxemia Hepatorenal syndrome Hypoglycemia Duodenal ulcer Gallstones Spontaneous bacterial peritonitis Hepatic encephalopathy Primary hepatocellular carcinoma

Anesthesia Management:

Anesthesia Management Consider the trauma patient and the relationship to alcohol (1/2 of all traumas are related to etoh consumption) Etoh abusers have increased likelyhood of ascites, sepsis,COPD Increased morbidity and mortality with surgery in this population

Preoperative preparation:

Preoperative preparation

Morbidity /Mortality:

Morbidity /Mortality Identify and manage comorbidities Cardiorespiratory function,coagulation status,renal function,fluids and electrolytes,nutrition Vit K for prolonged PT (severe hepatocellar disease if Vit K does not improve PT) Thrombocytopenia, administer platelets Hypoglycemia, give perioperative glucose soln Preop diuresis indicates adequate hydration

Chronic etoh ingestion:

Chronic etoh ingestion Increased requirement of inhaled anesthetics Increased requirement for induction agents Presence of cardiomyopathy may make them sensitive to cardiodepressant effects Decreased response to catecholamines Decreased protein binding increases free fraction Jaundiced patients may develop acute renal failure, sepsis. Suggest Mannitol , antibiotics preop .

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