AUTHOR AND EDITOR INFORMATION

Section 1 of 9  

• Authors and Editors
• Introduction
• Surgical Risk Assessment
• Preoperative Assessment
• Intraoperative Factors
• Postoperative Monitoring
• Conclusion
• Multimedia
• References

INTRODUCTION

Section 2 of 9  

• Authors and Editors
• Introduction
• Surgical Risk Assessment
• Preoperative Assessment
• Intraoperative Factors
• Postoperative Monitoring
• Conclusion
• Multimedia
• References

The number of patients with cirrhosis who require surgery is on the rise. Despite advances in antiviral therapeutics, cirrhosis secondary to hepatitis C and chronic alcohol abuse continues to grow. At the same time, medications and treatments aimed at improving survival in these patients have been increasing. Therefore, it can be expected that a growing number of patients with liver disease will undergo surgery. An estimated 1 in 700 patients admitted for elective surgery has abnormal liver enzyme levels. Some have estimated that as many as 10% of patients with advanced liver disease will undergo surgery in the last 2 years of their lives (Garrison, 1984). This article focuses on the challenging perioperative care of patients with liver disease.

Identification of the surgical risk is imperative in the care of any patient. Patients with liver disease are at particularly high risk for morbidity and mortality due to both the stress of surgery and the effects of general anesthesia. In 2003, del Olmo et al compared 135 patients with cirrhosis with 86 patients without cirrhosis, all undergoing nonhepatic general surgery. At 1 month, mortality rates were 3.5% for patients with cirrhosis compared with the control group. What is further evident in the literature is that decompensated liver disease increases the risk of postoperative complications (eg, acute hepatic failure, sepsis, bleeding). Assessing risk in these patients is a challenging but important endeavor.

The liver is vital for protein synthesis, glucose homeostasis, bilirubin excretion, and toxin removal, among other critical functions. In general, the liver has a substantial functional reserve because of its dual blood supply: portal-venous (75%) and hepatic-arterial (25%). Hence, clinical manifestations of liver damage occur only after considerable injury. Liver disease comprises a large spectrum of hepatic dysfunction. It includes asymptomatic transaminitis, cirrhosis, and end-stage liver disease. The most common causes of advanced liver disease are viral infection (hepatitis C and B), alcohol abuse, autoimmune disease, drugs or toxins, metabolic disorders (eg, involving alpha-1 antitrypsin, hemochromatosis, copper), and biliary tract diseases.

For excellent patient education resources, visit eMedicine's Hepatitis Center and Liver, Gallbladder, and Pancreas Center. Also, see eMedicine's patient education articles Liver Transplant and Cirrhosis.

SURGICAL RISK ASSESSMENT

Section 3 of 9  

• Authors and Editors
• Introduction
• Surgical Risk Assessment
• Preoperative Assessment
• Intraoperative Factors
• Postoperative Monitoring
• Conclusion
• Multimedia
• References

Bases of risk assessment

Secondary to the loss of hepatic reserve capacity, patients with liver disease have an inappropriate response to surgical stress and are at an increased risk of bleeding and postoperative hepatic coma or death. Therefore, the decision to perform surgery in these patients must be heavily weighed. Prediction of surgical risk is based on the degree of liver dysfunction, the type of surgery, and the preclinical status of the patient. Comorbid conditions responsible for perioperative morbidity and mortality (eg, coagulopathy, intravascular volume, renal function, electrolytes, cardiovascular status and nutrition) should be identified and addressed before surgery. Optimal preparation may decrease death and complications after surgery; issues to address include acute liver or renal failure, coagulopathy, adult respiratory distress syndrome, sepsis, and encephalopathy (Mueller, 2004; Ziser, 1999).

The extent of liver dysfunction and type of surgery play key roles in determining a patient's specific risk. In addition, liver disease can affect almost every organ and system in the body, including the heart and circulatory system, the brain, the lungs, the immune system, and the kidneys. The extent to which secondary manifestations of liver disease affect these systems may be just as important as the manifestations of primary liver dysfunction in predicting the outcome after surgery. As such, they deserve equal attention.

Quantitative risk stratification

Two risk stratification schemes have been developed to assess the perioperative risk of patients with cirrhosis: the Child-Pugh score and the Model of End-Stage Liver Disease (MELD) score. The Child-Turcotte-Pugh score is used to predict perioperative morbidity and mortality rates for patients undergoing intra-abdominal surgery. It incorporates a combination of 3 biochemical elements (ie, prothrombin time, albumin level, bilirubin level) and 3 clinical features (ie, nutritional state, presence of ascites, encephalopathy) to assess the primary functions of the liver. It was originally derived from patients undergoing portosystemic shunting for variceal hemorrhage; however, subsequent studies showed it to be useful in estimating risks for patients with liver disease undergoing hepatic and nonhepatic surgery (Garrison, 1984; Leonetti, 1984; Cryer, 1985; Mansour, 1997). (See the Table below.)

On average, patients with Child-Pugh class A disease can expect a 10% perioperative morbidity and mortality rate with intra-abdominal surgery. Predicted perioperative morbidity and mortality rates are 30% and 82%, for class B and class C cirrhosis, respectively. Patients with Child-Pugh class B disease are candidates for liver transplantation (Child, 1964). Patients with Child class B and C have worsened outcomes. The Child-Pugh score is correlated with perioperative mortality in patients undergoing nonshunt surgery and in patients with cirrhosis who are undergoing abdominal procedures. The Child-Pugh score has been challenged for its ambiguity and interobserver variability because of its inclusion of subjective parameters (eg, ascites, encephalopathy). It has also been criticized because it does not distinguish among patients in the same class (Trotter, 2004).

The MELD was developed in 1999 at the Mayo Clinic to apply objective assessment in predicting 3-month mortality in patients with chronic liver disease. It has been used to make predictions about patients undergoing transjugular intrahepatic portosystemic shunt (TIPS) and as a tool to prioritize patients with cirrhosis who are awaiting liver transplantation.

The MELD score is based on a patient's serum bilirubin, creatinine, and international normalized ratio (INR) for prothrombin time and is calculated from a validated predictive equation, as follows: (3.8 X In bilirubin value) + (11.2 X In INR) + (9.6 In creatinine value), where bilirubin and creatinine values are in milligrams per deciliter. The United Network for Organ Sharing (UNOS) provides an online calculator available at the UNOS MELD calculator. Although it originally included the etiology of liver failure, this criterion was subsequently dropped from the equation because it was proved to be prognostically insignificant.

Patients with a MELD score of less than 8 generally do well after TIPS, whereas those with a score of greater than 18 have a poor outcome. Best outcomes have been seen in patients with a MELD score of less than 14. For patients with a MELD score of 15-24, clinical judgment and further discussion with the family and the patient are necessary to weigh the risks and benefits of the procedure.

Avoidance of TIPS, if possible, is generally recommended in patients with a MELD score of greater than 24 unless the procedure is used as a last resort to control active variceal bleeding. A MELD score of greater than 24 generally qualifies a patient for liver transplantation. However, a MELD score of at least 8 is predictive of a poor outcome in patients with liver disease who undergo cardiac surgery or cholecystectomy. A MELD score of at least 8 has a sensitivity of 91% and a specificity of 77% for predicting postoperative morbidity (Perkins, 2004; Suman, 2004).

In general, the MELD score fairs well compared with the Child-Pugh score, though some might argue that the MELD score may be a more objective predictor of postoperative mortality than the Child-Pugh score (Farnsworth, 2004; Perkins, 2004; Suman, 2004; Befeler, 2005). However, it is principally used to select patients for liver transplantation. Whether this model is valid for predicting surgical risk outside the setting of liver transplantation is yet to be determined. The Child-Pugh classification is currently the best validated predictor of surgical risk in patients with cirrhosis.

Child-Pugh Classification of Liver Disease

PREOPERATIVE ASSESSMENT

Section 4 of 9  

• Authors and Editors
• Introduction
• Surgical Risk Assessment
• Preoperative Assessment
• Intraoperative Factors
• Postoperative Monitoring
• Conclusion
• Multimedia
• References

Asymptomatic patients

Evaluation of any patient undergoing surgery should include thorough history taking and physical examination. In asymptomatic patients, this is an extremely valuable screening tool. Risk factors (eg, previous blood transfusions, tattoos, illicit drug use, sexual promiscuity, alcohol use, family or personal history of jaundice, adverse effects to anesthesia, complete review of medications) for liver disease should be explored. Symptoms or physical signs suggestive of liver dysfunction should be further explored with liver functions tests, coagulation studies, complete blood count determination, and electrolyte panel. However, routine preoperative testing of liver function is not recommended because of the low prevalence of liver abnormalities in clinically asymptomatic patients (Schemel, 1976; Robbins, 1979).

Asymptomatic patients with significantly abnormal liver function should have their elective surgery postponed and their liver disease investigated; their perioperative risk should be reassessed after their liver dysfunction is characterized (Rizvon, 2003).

Known liver disease

In patients with known liver disease, optimal preparation for surgery that appropriately addresses the primary features of liver disease may decrease the risk of complications or death after surgery. At first, the overall health of the liver is important to assess. The etiology of liver disease is important to elicit from the patient's history. Physical examination should focus on ascites and the stigmata of chronic liver disease (eg, spider angioma, jaundice, gynecomastia, palmar erythema, scleral icterus, asterixis, encephalopathy). Laboratory tests should target coagulopathy, electrolyte abnormalities, and the complete blood count. Coagulopathy, ascites, and encephalopathy should be addressed before surgery.

Most studies in the literature have focused on patients with end-stage liver disease or cirrhosis; relatively little is known about surgical risk in patients with other liver diseases. However, elective surgery is contraindicated in patients with ongoing hepatocyte damage, as seen in acute liver diseases, such as viral and alcoholic hepatitis. Patients with these conditions tend to have morbidity rates higher than those with chronic cholestatic disease. Therefore, it is prudent to postpone surgery until transaminitis is resolved (Powell-Jackson, 1982). The risk of surgery in patients with alcoholic liver disease depends on the severity of liver dysfunction. Although patients with fatty liver tolerate surgery well, increased postoperative morbidity and mortality are associated with alcoholic hepatitis and cirrhosis (Rizvon, 2003).

In addition, it is worth noting that patients with a history of alcohol abuse have other complications, including poor wound healing, bleeding, withdrawal, delirium, and infections. Patients with chronic liver disease (including conditions such as chronic hepatitis C) whose liver function is preserved may not have an increased operative risk (Friedman, 1999). Elective surgery in patients with alcoholic hepatitis is associated with a high mortality rate unless the procedure is deferred until prolonged abstinence is achieved and biochemical and clinical progress is noted.

Coagulopathy

Of no surprise, coagulopathy is one of the primary features of chronic liver disease because all the coagulation factors are produced in the liver (with the exception of von Willebrand factor). In addition, portal hypertension leads to hypersplenism, subsequent platelet trapping, and peripheral thrombocytopenia. Furthermore, cholestasis and malnutrition contribute to alterations in the results of coagulation tests. To correct such coagulopathies, replenishment of vitamin K, administration of fresh-frozen plasma (FFP) and platelets, and possibly cryoprecipitation are recommended to reduce a prothrombin time within 3 seconds of normal and to achieve a goal of platelet counts of >50 X 10³/L. (The goal platelet count may vary depending on the type of surgery and the surgeon.) A prolonged bleeding time can be corrected with diamino-8-D-arginine vasopressin (DDAVP) (Burroughs, 1985).

Ascites

In 1 study, ascites in patients with cirrhosis was associated with a 37-83% mortality rate compared with 11-53% in those without ascites (Conn, 1991). Ascites can cause respiratory compromise secondary to reduced lung expansion, abdominal-wall herniation, and wound dehiscence. In general, ascites should be treated aggressively with diuretics and/or large-volume paracentesis with albumin if necessary before surgery. Ascitic fluid should also be analyzed to rule out spontaneous bacterial peritonitis. If the ascites is not completely treated before surgery, it can be drained at laparotomy (Friedman, 1999).

Encephalopathy

Before surgery, many patients with cirrhosis may have encephalopathy, which increases their risk of postoperative encephalopathy. A retrospective study of 40 patients with chronic liver failure undergoing nonhepatic surgery demonstrated that encephalopathy was associated with an 88% risk of mortality, which was even higher than the 50% risk associated with emergency surgery (Rice, 1997).

Infection, diuretics, metabolic alkalosis, constipation, use of CNS depressants, hypoxia, sepsis, azotemia, or gastrointestinal bleeding in the preoperative and postoperative periods may precipitate encephalopathy. Correction of electrolyte abnormalities, treatment of infection and gastrointestinal bleeding, and restriction of sedatives help prevent encephalopathy. It is often treated by administering lactulose with or without neomycin and by managing the underlying precipitant.

Malnutrition

Severe malnutrition is associated with an increased need for packed red blood cells, FFP, and cryoprecipitate during liver transplantation. It is also associated with a prolonged postoperative stay. Stephenson et al (2001) suggest that preoperative improvement in the patient's nutritional status may improve outcomes.

In patients with end-stage liver disease, parenteral and enteral nutrition should be started, preferably in the preoperative period, because they are expected to have increased energy expenditure after surgery (Weimann, 1998). Of importance, certain types of nutritional supplementation may aggravate the tendency for hepatic encephalopathy; therefore, use high-carbohydrate and/or high-lipid supplements with a decreased amino acid content (Wiklund, 2004). Patients with alcoholic liver disease and Wernicke encephalopathy benefit from preoperative vitamin B1 supplementation. Liver disease can also trigger hypoglycemia.

Other preoperative evaluation

An important consideration not to be overlooked is the preoperative cardiopulmonary evaluation. This is required in all patients, regardless of the functional status of their liver. Cardiac risk stratification should include an assessment of functional capacity (metabolic equivalent [MET] or exercise duration) and stress testing (exercise ECG, dipyridamole thallium test, or dobutamine stress echocardiography), if it is performed. Surgery-specific risk also had a pivotal role in cardiac risk assessment. Cardiac surgery performed in patients with cirrhosis is associated with a high surgical mortality rate.

In 1997, the American College of Physicians published guidelines in the form of algorithms for assessing and managing perioperative risks based on the results of the tests mentioned above. The Goldman cardiac risk index is used to predict postoperative pulmonary and cardiac complications (Lawrence, 1996). It is a classification system based on points assigned to a patient's clinical history, physical findings, ECGs, general medical status (based on arterial blood gases [ABGs], electrolytes, and liver disease), and type of operation.

In addition, the commonly used classification by the American Society of Anesthesiologists (ASA) is correlated with pulmonary risk (Hall, 1991; Kroenke, 1992). ASA criteria are based on comorbid conditions that are a threat to life or that limit activity and thus help in predicting preoperative risks. An ASA class higher than 2 increases the risk 1.5- to 3.2-fold (Smetana, 1999).

INTRAOPERATIVE FACTORS

Section 5 of 9  

• Authors and Editors
• Introduction
• Surgical Risk Assessment
• Preoperative Assessment
• Intraoperative Factors
• Postoperative Monitoring
• Conclusion
• Multimedia
• References

Patients with preexisting liver disease are most likely to have hepatic decompensation from anesthesia and surgery. In a study at the Mayo Clinic, investigators reviewed 733 patients with cirrhosis who underwent surgery (Ziser, 1999). They found an 11.6% perioperative mortality rate (within 30 days of surgery) and a 30.1% complication rate, which is notably higher than that expected for patients without liver dysfunction. Postoperative pneumonia was the most frequent complication. Risk factors included male sex, diagnosis of cirrhosis (excluding primary biliary cirrhosis), high Child-Pugh score, ascites, an elevated serum creatinine value, preoperative gastrointestinal bleeding, and intraoperative hypotension.

Anesthesia

Patients with liver disease are more likely than patients without liver disease to have hepatic decompensation with anesthesia (Friedman, 1999). In general, any or all of the functions of the liver may be impaired in patients with liver disease. Most relevant are changes in plasma-binding proteins and alterations in the detoxification and excretion process. Hypoalbuminemia impairs drug binding and metabolism and elevates serum drug levels. As a consequence, the absorption, distribution, metabolism, and excretion of anesthetics, muscle relaxants, analgesics, and sedatives may be affected.

General anesthesia also reduces total hepatic blood flow, especially the contribution of the hepatic artery. In addition, patients with liver disease tend to have several baseline cardiovascular abnormalities, including decreased systemic vascular resistance and increased cardiac index, which may further influence hepatic blood flow. The result of this reduction is drastic loss of their remaining marginal hepatic function.

Of all the inhaled anesthetics, halothane and enflurane appear to reduce hepatic artery blood flow the most because of systemic vasodilation and a mild negative inotropic effect (Batchelder, 1975; Ngai, 1980; Strunin, 1992; Friedman, 1999). Halothane is also associated with the greatest risk of hepatotoxicity, with the incidence of fulminant hepatitis approximating 1 case in 6,000-35,000 patients after exposure (Gut, 1998). This concern has all but eliminated its use in adults in the United States. However, isoflurane is a safer choice than halothane in patients with liver disease because it may increase hepatic blood flow. It is the preferred anesthetic agent in patients with liver disease (Maze, 1994). Newer haloalkanes, such as sevoflurane and desflurane, also undergo less hepatic metabolism than halothane or enflurane.

The drug affect of neuromuscular blocking agents may be prolonged in patients with liver disease. Atracurium has been recommended as the agent of choice because it relies on neither the liver nor kidney for excretion (Maze, 1994). Likewise, drugs such as morphine, meperidine, benzodiazepines, and barbiturates should be used with caution because of their dependence on the liver for metabolism. In general, their doses should be decreased by 50% (Gholson, 1990). Fentanyl is the preferred narcotic (Friedman, 1987).

Surgery

The type of surgery is an extremely important determinant of postoperative hepatic dysfunction (Friedman, 1987). Because of traction on abdominal viscera, intra-abdominal operations are more likely than extra-abdominal surgeries to cause reflex systemic hypotension and to subsequently reduce hepatic blood flow. Also, catecholamine response is impaired in patients with liver disease; therefore, intraoperative hypovolemia or hemorrhage may not trigger adequate compensatory mechanisms. Anesthetics causing sympathetic blockade further blunt this response.

Surgeries that result in a large amount of blood loss increase the risk for ischemic hepatic injury. Sufficient surgical hemostasis and autologous platelet-rich plasma were useful for prevention of massive hemorrhage (Mansour, 1997; Mueller, 2004). As described above, emergency surgery is associated with morbidity and mortality rates higher than those of elective surgery.

Elective surgery

Cholecystitis and cholelithiasis are common in patients with liver disease. The odds ratio for perioperative mortality in patients with liver disease who undergo cholecystectomy is 8.47 (Friedman, 1999). In fact, open cholecystectomy in patients with cirrhosis has been called a formidable operation, though recent studies have demonstrated lowered but still considerable mortality rates in patients with cirrhosis who undergo abdominal surgery. However, laparoscopic cholecystectomy can be safely performed in selected patients who have well-compensated cirrhosis and no signs of portal hypertension (Friedman, 1999).

A case-controlled retrospective review of laparoscopic cholecystectomy in 48 patients with Child-Pugh A (80% of patients) and Child-Pugh B cirrhosis demonstrated no increase in morbidity and mortality rates or worsening of outcome compared with control subjects (Fernandes, 2000). Another small series had similar results (D'Albuquerque, 1995); the authors concluded that laparoscopic cholecystectomy is relatively safe in patients with Child-Pugh A or B cirrhosis. However, other studies with cholecystectomy showed results less impressive than these when patients with Child-Pugh class C cirrhosis (Garrison, 1984; Mansour, 1997).

A large study of 747 patients from 1990-1997 who underwent liver resection demonstrated that mortality was significantly higher in patients with cirrhosis (8.7%) or obstructive jaundice (21%) than in patients with a normal liver (1%; P < .001) (Belghiti, 2000).

Cardiac surgery in patients with cirrhosis is associated with a high operative mortality rate (Friedman, 1999). Friedman et al found the following risk factors for operative mortality: obstructive jaundice, hematocrit value less than 30%, serum bilirubin level of more than 11 mg/dL, malignant biliary obstruction, azotemia, and cholangitis.

In some parts of the world, parasitic diseases, such as hydatid disease or echinococcosis, may cause liver lesions that need to be surgically removed. In such cases, the surgical technique is important, and sepsis can cause perioperative morbidity (Atmatzidis, 2005).

Emergency surgery

Patients undergoing emergency surgery are at substantial risk for liver dysfunction. Intuition suggests, the more urgent the surgery, the less opportunity available to correct reversible factors, such as electrolyte abnormalities, coagulopathy, and clinical manifestations of portal hypertension (eg, ascites, hepatic encephalopathy).

Emergency surgery is an important predictor of adverse outcome (Garrison, 1984). In a series of 100 patients with cirrhosis who underwent abdominal surgery for a variety of reasons, 80% of nonsurvivors and 40% of survivors who had serious complications underwent emergency surgery (Garrison, 1984).

A series of 92 patients with cirrhosis who underwent abdominal surgeries had a 50% mortality rate in association with emergency procedures (22% for Child-Pugh A, 38% for Child-Pugh B, 100% for Child-Pugh C) versus 18% for elective surgery (P = .001) (Mansour, 1997). This study showed that the most accurate predictor of outcome is the patient's preoperative Child-Pugh class. Yet another study demonstrated that patients with cirrhosis had a higher perioperative morbidity and mortality rate with emergency surgery than with elective surgery. Mortality rates significantly differ between the groups (emergency group, 1 mo = 19%, 3 mo = 44%; elective group, 1 mo = 17%, 3 mo = 21%; P < .05) (Farnsworth, 2004).

Alternatives to surgery

Relatively noninvasive techniques or advances in medical management have replaced surgical intervention for many conditions (eg, extrahepatic biliary obstruction, refractory variceal hemorrhage, coronary artery disease). TIPS has become the treatment of choice for managing most cases of refractory variceal bleeding, and surgical shunts are created only in special circumstances. Percutaneous stenting or endoscopic retrograde cholangiopancreatography (ERCP) is now commonly used for biliary strictures and choledocholithiasis. Coronary angioplasty and percutaneous coronary interventions have decreased the need for coronary artery bypass grafting. The use of proton-pump inhibitors along with antibiotic treatment of Helicobacter pylori has usurped the need for surgical treatment of peptic ulcer disease with antrectomy and/or vagotomy.

POSTOPERATIVE MONITORING

Section 6 of 9  

• Authors and Editors
• Introduction
• Surgical Risk Assessment
• Preoperative Assessment
• Intraoperative Factors
• Postoperative Monitoring
• Conclusion
• Multimedia
• References

In patients with cirrhosis, liver failure is the most common cause of postoperative death (Friedman, 1987). Hepatocellular injury is most commonly due to the effects of anesthesia, intraoperative hypotension, sepsis, or viral hepatitis. A low threshold is generally maintained for postoperative transfer to the intensive care unit (ICU). Patients must be observed closely for signs of acute hepatic decompensation, such as worsening jaundice, encephalopathy, and ascites. Sedative and pain medications should be carefully titrated to prevent an exacerbation of hepatic encephalopathy. Renal function should also be monitored because of the risk of hepatorenal syndrome and fluid shifts that occur as a result of surgery. Early enteral feeding has been suggested to improve outcomes.

Serious sequelae of decompensated hepatopathy include severe sepsis and secondary disseminated intravascular coagulation (DIC). These potential complications emphasize the need for maintaining a low threshold for ICU-level monitoring.

Patients with Wilson disease who are taking D-penicillamine may have impaired wound healing; therefore, the dose should be decreased in the first 7-14 days after surgery.

Considering a patient's functional status before liver transplantation, in addition to review of conventional clinical factors, may help improve the clinician's ability to predict survival after transplantation (Jacob, 2005).

CONCLUSION

Section 7 of 9  

• Authors and Editors
• Introduction
• Surgical Risk Assessment
• Preoperative Assessment
• Intraoperative Factors
• Postoperative Monitoring
• Conclusion
• Multimedia
• References

Surgery in a patient with liver disease poses a formidable challenge for all physicians involved. Targeted interventions before surgery may help to prevent complications and improve outcomes. The cornerstones of perioperative management are medical treatment of the complications of liver disease, including coagulopathy, ascites, encephalopathy, and malnutrition. Evolving knowledge of the effects of anesthesia, improving surgical techniques, and use of improved diagnostic tests will help reduce perioperative complications (Rizvon, 2003). Sepsis, coagulopathy, and emergency surgery are most strongly correlated with postoperative mortality. Therefore, a multidisciplinary approach to postoperative care is imperative and should include input from anesthesiologists, surgeons, internists, and hepatologists.

General considerations are as follows (see Media file 1):

• Surgery is contraindicated in patients with Child-Pugh Class C, acute hepatitis, severe coagulopathy, severe chronic hepatitis, or severe extrahepatic manifestations of liver disease (eg, acute renal failure, hypoxia, cardiomyopathy).
• Avoid surgery if possible in patients with a MELD score of greater than or equal to 8 or Child-Pugh Class B unless they have undergone a thorough preoperative evaluation and preparation.
• Use caution with sedatives and neuromuscular blocking agents.
• Optimize medical therapy for patients with cirrhosis.
• • Correct coagulopathy with vitamin K and FFP to achieve prothrombin time within 3 seconds of normal.
  • The goal platelet count is >50-100 X 10³/L.
  • Minimize ascites to decrease risk of abdominal-wall herniation, wound dehiscence, and problems with ventilation.
  • Address nutritional needs.
  • Monitor renal function.
  • Monitor and correct electrolyte abnormalities, especially hypokalemia and metabolic alkalosis.
• Perform close postoperative monitoring.
• • Admission to the ICU may be appropriate after prolonged surgeries, intraoperative hypotension, excessive blood loss, or cardiac and/or pulmonary surgery.
  • Monitor for signs of acute liver failure, including worsening jaundice, encephalopathy, and ascites.

MULTIMEDIA

Section 8 of 9  

• Authors and Editors
• Introduction
• Surgical Risk Assessment
• Preoperative Assessment
• Intraoperative Factors
• Postoperative Monitoring
• Conclusion
• Multimedia
• References

Media file 1:  Algorithm for a patient with liver disease considering surgery.
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Media type:  Graph

REFERENCES

Section 9 of 9

• Authors and Editors
• Introduction
• Surgical Risk Assessment
• Preoperative Assessment
• Intraoperative Factors
• Postoperative Monitoring
• Conclusion
• Multimedia
• References

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Article Last Updated: Dec 19, 2006