jean mantz, md, phd professor of anesthesia and critical care chairman, department of anesthesia and...
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![Page 1: Jean Mantz, MD, PhD Professor of Anesthesia and Critical Care Chairman, Department of Anesthesia and Critical Care, Beaujon University Hospital INSERM](https://reader035.vdocuments.net/reader035/viewer/2022062518/56649e735503460f94b73618/html5/thumbnails/1.jpg)
Jean Mantz, MD, PhDProfessor of Anesthesia and Critical Care
Chairman, Department of Anesthesia and Critical Care, Beaujon University Hospital
INSERM U 676University of Paris
Principles of anesthesia in cirrhotic patients
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Anesthesia and cirrhosis
Principles of perioperative management Anesthesia and cirrhosis in:
Liver transplantation Liver resection Endoscopic procedures
Conclusion
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Risk factorsMorbidity(%)
30 day mortality(%)
6 month mortality(%)
Child-Pugh score C vs AB 42 15 31
Ascite 48 20 39
Renal failure 42 21 36
COPD 41 18 29
Preoperative sepsis 74 49 60
GI bleeding 70 12 23
ASA status 4 or 5 68 32 52
Major surgery (thoracic, voies biliary, abodminal, septic)
39 12 23
Intraoperative hypotension 45 15 26
Cause other than PBC 33 14 24
Cirrhotic patients: Risk factors for perioperative morbi-mortality Ziser et al Anesthesiology 1999; 90: 42-53
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Risk factorsMorbidity(%)
30 day mortality(%)
6 month mortality(%)
Child-Pugh score C vs AB 42 15 31
Ascite 48 20 39
Renal failure 42 21 36
COPD 41 18 29
Preoperative sepsis 74 49 60
GI bleeding 70 12 23
ASA status 4 or 5 68 32 52
Major surgery (thoracic, voies biliary, abodminal, septic)
39 12 23
Intraoperative hypotension 45 15 26
Cause other than PBC 33 14 24
Cirrhotic patients: Risk factors for perioperative morbi-mortality Ziser et al Anesthesiology 1999; 90: 42-53
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Risk factorsMorbidity(%)
30 day mortality(%)
6 month mortality(%)
Child-Pugh score C vs AB 42 15 31
Ascite 48 20 39
Renal failure 42 21 36
COPD 41 18 29
Preoperative sepsis 74 49 60
GI bleeding 70 12 23
ASA status 4 or 5 68 32 52
Major surgery (thoracic, voies biliary, abodminal, septic)
39 12 23
Intraoperative hypotension 45 15 26
Cause other than PBC 33 14 24
Cirrhotic patients: Risk factors for perioperative morbi-mortality Ziser et al Anesthesiology 1999; 90: 42-53
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Venous compliance in cirrhosisHadengue et al, Hepatology 1992
0
5
10
15
20
25
30
35
Controls Child-Pugh AB Child-Pugh C
Ind
ex c
ard
iaq
ue
(% v
aria
tio
n)
300 mL gélatine en 3 min300 mL gélatine en 3 min
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Fluid management
Hypovolemia Fluid overload
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Preoperative risk evaluation
– Circulatory (hyperkinetic profile with low SVR, high venous compliance, coronaropathy or cardiomoypathy, pulmonary hypertension)
– Ventilatory (Hypoxemia, intrapulmonary shunt, restrictive syndrome (ascite, pleural effusion)
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Preoperative risk evaluation
– Circulatory (hyperkinetic profile with low SVR, high venous compliance, coronaropathy or cardiomoypathy, pulmonary hypertension)
– Ventilatory (Hypoxemia, intrapulmonary shunt, restrictive syndrome (ascite, pleural effusion)
– Renal (hypovolemia, hepatorenal syndrome)– Cerebral (encephalopathy, cerebral edema)– Coagulation (hypo-/ hypercoagulability, fibrinolysis)– Pharmacokinetic/dynamic changes to drug effects
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Choice of anesthetic agents/techniques
• Risks of regional anesthesia• Use intravenous anesthetics with elimination
independent from cytochrome P450 activity (Propofol AIVOC, ketamine, etomidate, fentanyl, sufentanil, remifentanil, atracurium/cisatracurium)
• Volatile anesthetics: desflurane/sevoflurane• Maintain hemodynamic stability +++
• MONITOR and TITRATE+++
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Patient
Surgeon
Hepatologist/
Gastroenterologist
Anesthesiologist
Risk/benefit balance
of anesthesia and surgery
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Short acting anestheticsPostoperative analgesia Prevention of PONVReversal of muscle relaxants Maintenance of normovolemia, hemoglobin levelsPrevention of awarenessMaintenance of normothermiaMaintain oxygenationRestrictive fluid therapyAvoid hyperglycemiaStart postoperative rehabilitation
Intraoperative period
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Short acting anestheticsPostoperative analgesia Prevention of PONVReversal of muscle relaxants Maintenance of normovolemia, hemoglobin levelsPrevention of awarenessMaintenance of normothermiaMaintain oxygenationRestrictive fluid therapyAvoid hyperglycemiaStart postoperative rehabilitation
Intraoperative period
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Cirrhosis and coagulation abnormalities
Antihemostatic Prohemostatic
ThrombocytopeniaAlteration of platelet functions
FvW and FVIII
Factors II, V, VII, IX, X, XIAbnormalities of fibrinogen
Protein C, protein S, protein Z, AT(III), heparin-CoFII, 2-macroglobulin
2-anti-plasmine, TAFI
t-PA
plasminogen PAI-1
T. Lisman et al. J Hepatol 2002;37:280-7
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Hepatology 2006,44:53-61
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Cirrhosis
Coagulation abnormalities
Hemorrhage
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Cirrhosis
Coagulation abnormalities
Hemorrhage
Portal hypertension
?
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Multimodal analgesia
Early extubation
Early removal of tubes and catheters
Early mobilization
Thromboprophylaxis
Early enteral nutrition
Hydratation
Postoperative rehabilitation
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Multimodal analgesia
Early extubation
Early removal of tubes and catheters
Early mobilization
Thromboprophylaxis
Early enteral nutrition
Hydratation
Postoperative rehabilitation
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Liver transplantation in Beaujon: recipients
26%6%
14%
7%
17%30%
cirrhosis
HcC
biliary
ALF
redux
others
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2005-2007 (n=215)
1997-2000 (n=212)2001-2004 (n=242)
1993-1996 (n=77)
1989-1992 (n=51)
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Cirrhosis (n=416)
Others (n=72)
HCC (n=248)
Fulminans (n=139)
Survival / indications
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Anesthesia for endoscopic procedures.
• High risk anesthesia +++– Outside the OR– Inhalation of gastric content– Obstructive hypoxemia– Hemorrhage and perforation– Pulmonary hypertension
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Indications for endotracheal intubation
• Esophageal varices treatment (inhalation risk+++)
• Radiofrequency (painful procedures)
• Other indications:– Long duration procedure (> 1h))– Comorbidities (obesity, major ascite,
diabetic dysautonomia)
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Conclusion
• Cirrhotic patients are at high risk of postoperative morbi-mortality
• Discuss the risk/benefit balance of surgery and anesthesia
• Maintain hemodynamic stability (monitor, titrate)
• There is no « minor » anesthesia
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