Everyday Challenges In Clinical Practice: Peshawar Meeting November 2017

PSH 2017

Peshawar Meeting November 2017

EVERYDAY CHALLENGES IN CLINICAL PRACTICE

Objectives

PSH 2017

• Review basic principles of pre op assessment of patients with liver disease • Effects of anesthesia and surgery on the liver • Estimation of operative risk • Risk associated with specific types of Surgery • Discuss strategies to optimize pre op management of liver diseases • Choice of sedation for surgery

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SCREENING FOR LIVER DISEASE BEFORE SURGERY • HISTORY – – – – – – – –

prior blood transfusions tattoos illicit drug use sexual promiscuity family history of jaundice or liver disease history of jaundice or fever following anesthesia alcohol use (current, prior and quantity) complete review of current medications

Clinical features • • • • • •

Increased abdominal girth Jaundice Palmar erythema Spider telangiectasias Splenomegaly Gynecomastia and testicular atrophy in men

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Effects of anesthesia on the liver Hepatic ischemia: elevated transaminases Cirrhosis Hyperdynamic circulation with decreased blood flow to liver More susceptible to hypoxemia and hypotension • Surgical factors contributing to hepatic ischemia: • Hypotension, hemorrhage, vasoactive medications • Positive pressure ventilation

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Metabolism of medications • Volume of distribution of medications is increased in cirrhotic patients. • Inhaled anesthetic choice • Halothane dcrease hepatic blood flow and can cause hepatotoxicity • Isoflurane, sevoflorane and desflorane has less effect on hepatic blood flow and hepatotoxicity

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Metabolism of medications • Atracurium/cisatracurium preferred—not excreted by liver or kidney • Sedatives and narcotics can precipitate hepatic encephalopathy and prolong periods of depressed consciousness.

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• What are the postoperative concerns

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Coagulopathy • • • •

Decreased production of clotting factors Depletion of vitamin K stores Increased fibrinolytic activity Thrombocytopenia

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Ascites • Hepatic hydrothorax—respiratory complications • Wound complications • Hernia

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Hepatic encephalopathy • • • • • •

Precipitating factors in post operative period Volume contraction Hypokalemia Infection Bleeding Medications

Renal Dysfunction

• • • • •

Potential causes: Intravascular volume depletion Nephrotoxicity ATN Hepatorenal syndrome (HRS)

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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

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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

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ESTIMATING SURGICAL RISK • Appraisal of the severity of liver disease • The urgency of surgery (and alternatives to surgery) • Coexisting medical illness. • Surgical risk assessment is less relevant if immediate surgery is required to prevent death. • Elective procedures • Risk assessment • Optimization of the patient's medical status

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Study Design Flaws • • • •

Mostly small studies Retrospective Clinical experience Arbitrary parameters

Contraindications for elective surgery

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 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. Powell-Jackson P, Greenway B, Williams R. Adverse effects of exploratory laparotomy in patients with unsuspected liver disease. Br J Surg 1982; 69:449.

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PATIENTS AT VARIABLE INCREASED RISK • The risk of surgery in patients with cirrhosis depends – the severity of disease, – the clinical setting – type of surgical procedure

SCORING SYSTEMS TO ASSESS SURGERY RISK 1.CTP 2.MELD 3.ASA

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Child-Turcotte-Pugh score

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ASA Classification

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• In a retrospective study of 261 patients (45 with cirrhosis and 216 matched controls without cirrhosis) undergoing cardiac surgery between 1992 and 2009, • CP < 8 : 95 % survival rate at 90 days • CP > 8 : 30 % survival rate at 90 days

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MELD score • MELD is supplanting the CP classification as the principal method for determining surgical risk • The MELD score, American Society of Anesthesiologists (ASA) class, and age predicted mortality in a study of 772 patients with cirrhosis who underwent major digestive, orthopedic, or cardiovascular surgery. • The MELD score was the best predictor of 30- and 90-day mortality. Mortality at 30 days ranged from 6 percent (MELD score, <8) to more than 50 percent (MELD score,

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• • • • • •

Increased risk of mortality up to 90 days postoperatively Mortality rates MELD <7: 5.7% MELD 8-11: 10.3% MELD 12-15: 25.4% ASA class IV adds 5.5 MELD points. ASA class V = 100% mortality

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• MELD < 10 : elective surgery • MELD 10 to 15 : elective surgery with caution • MELD >15 : should not undergo elective surgery

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• Obstructive jaundice — • Increased risk of perioperative complications Infections stress ulceration DIC wound dehiscence renal failure

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• An overall mortality rate of 9 percent was found in a large retrospective study that included 373 patients undergoing surgery for obstructive jaundice. • Multivariate analysis identified three predictors of postoperative mortality: – An initial hematocrit value <30 percent – An initial serum bilirubin level >11 mg/dL (200 micromoles/L) – A malignant cause of obstruction (eg, pancreatic carcinoma or cholangiocarcinoma)

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• A number of interventions have been attempted to reduce morbidity and mortality in these patients: – Perioperative administration of broad-spectrum intravenous antibiotics – External biliary drainage via a transhepatic approach – Endoscopic biliary drainage

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• Limited evidence suggests that the administration of bile salts or lactulose to patients with obstructive jaundice can prevent both the endotoxemia and the exaggerated renal vasoconstriction

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• Cardiac surgery —  Cardiac surgery is associated with increased mortality in patients with cirrhosis compared to other surgical procedures

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• • • • • •

9 studies involving 210 patients with cirrhosis Mortality : 17 %. CP A: 5% CP B : 35% CP C : 70% MELD score has not been adequately studied as a prognostic tool for patients undergoing cardiac surgery.

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• Risk factors for hepatic decompensation • total time of cardiopulmonary bypass • use of nonpulsatile as opposed to pulsatile cardiopulmonary bypass • need for perioperative pressor support • Thus, the least invasive options • Angioplasty, • Valvuloplasty

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• • • •

Hepatic resection — RESIDUAL VOLUME NEEDED Normal Liver 25% Cirrhotic liver 40%

• Risk factors for hepatic decompensation CTP MELD BILIRUBIN PT Portal Hypertension

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• A database study of 587 patients who underwent hepatic resection concluded that the Child-Turcotte-Pugh score and ASA score were better predictors of morbidity and mortality than the MELD

Schroeder et al Ann Surg 2006; 243:373.

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• Clinically significant portal hypertension • Gastroesophageal varices OR • Platelet < 100,000/mL with splenomegaly clinical decompensation after surgery  3 & 5 year mortality

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• 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)

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• 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

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• Colorectal surgery, primarily for diverticular disease and colorectal cancer, is associated with mortality rates as high as 26 percent in patients with cirrhosis

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• Less invasive approaches such as stent placement to relieve obstruction should be considered when possible.

• Elective umbilical hernia repair can be performed with excellent outcomes, even in patients with CP class C cirrhosis

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• Patients with minimally increased risk — • Mild to moderate chronic liver disease without cirrhosis • Mild chronic hepatitis

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• Fatty liver and nonalcoholic steatohepatitis

• Increased mortality following hepatic resection has been observed in those with moderate to severe steatosis (>30 percent of hepatocytes containing fat • NASH is associated with increased morbidity following hepatic resection

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• Recommending a period of abstinence from alcohol prior to surgery is advisable for all patients with the histologic appearance of steatohepatitis or those who are suspected of excessive alcohol consumption

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• 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.

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• Hemochromatosis — – Evaluation for complications Diabetes Cardiomyopathy

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• 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

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COAGULOPATHY • Management of haemostatic abnormalities in patients with cirrhosis  optimize the platelet count  optimize fibrinogen level  optimize renal function  avoid the INR values to guide therapy • A prolonged bleeding time can be treated with desmopressin (DDAVP).

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