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

Anesthesia and cirrhosis

Principles of perioperative management Anesthesia and cirrhosis in:

Liver transplantation Liver resection Endoscopic procedures

Conclusion

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

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

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

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

Fluid management

Hypovolemia Fluid overload

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)

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

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+++

Patient

Surgeon

Hepatologist/

Gastroenterologist

Anesthesiologist

Risk/benefit balance

of anesthesia and surgery

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

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

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

Hepatology 2006,44:53-61

Cirrhosis

Coagulation abnormalities

Hemorrhage

Cirrhosis

Coagulation abnormalities

Hemorrhage

Portal hypertension

?

Multimodal analgesia

Early extubation

Early removal of tubes and catheters

Early mobilization

Thromboprophylaxis

Early enteral nutrition

Hydratation

Postoperative rehabilitation

Multimodal analgesia

Early extubation

Early removal of tubes and catheters

Early mobilization

Thromboprophylaxis

Early enteral nutrition

Hydratation

Postoperative rehabilitation

Liver transplantation in Beaujon: recipients

26%6%

14%

7%

17%30%

cirrhosis

HcC

biliary

ALF

redux

others

2005-2007 (n=215)

1997-2000 (n=212)2001-2004 (n=242)

1993-1996 (n=77)

1989-1992 (n=51)

Cirrhosis (n=416)

Others (n=72)

HCC (n=248)

Fulminans (n=139)

Survival / indications

Anesthesia for endoscopic procedures.

• High risk anesthesia +++– Outside the OR– Inhalation of gastric content– Obstructive hypoxemia– Hemorrhage and perforation– Pulmonary hypertension

Indications for endotracheal intubation

• Esophageal varices treatment (inhalation risk+++)

• Radiofrequency (painful procedures)

• Other indications:– Long duration procedure (> 1h))– Comorbidities (obesity, major ascite,

diabetic dysautonomia)

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