Cirrhotic patients undergoing elective surgery present unique challenges

Cirrhosis is on the rise in the U.S., and yet the risk of dying from the disease is less than half of what it was in 1970. Anesthesiologists will likely encounter more patients with cirrhosis presenting for elective surgery as they await a liver transplant. This may include arthroscopy, head and neck surgery, hernia repair and cardiac surgery.

“Managing patients with end-stage liver disease is an increasing challenge for us,” said Geraldine C. Diaz, D.O., from the Department of Anesthesia and Critical Care, SUNY Downstate Medical Center. Dr. Diaz moderated the Monday session “The Cirrhotic Patient Presenting for Elective Surgery: Anesthesia Pearls and Pitfalls.”

Geraldine C. Diaz, D.O., discussed the risks associated with cirrhosis and elective surgery.

The session addressed the potential complications that can arise in cirrhotic patients perioperatively and the targeted aggressive therapies anesthesiologists can provide to optimize outcomes.

“Scarring of the liver affects blood flow and impairs the endothelium,” said panelist Michael A.E. Ramsay, M.D., FRCA, Chairman and Professor in the Department of Physiology at Baylor Health Care System in Dallas. “Complications of cirrhosis hit every organ and can cause frailty in patients.”

Cirrhotic patients can present with varices and portal hypertension that may cause bleeding during surgery. Other potential pitfalls include coagulation disorders, cirrhotic cardiomyopathy, renal dysfunction and hepatopulmonary syndrome, which can lead to hypoxia.

To optimize cirrhotic patients for elective surgery, “the first question to ask is: ‘Is this patient compensated or decompensated,’” said Cinnamon L. Sullivan, M.D., Director of Transplant Anesthesia at Emory University Hospital in Atlanta.

If your patient is compensated, the one-year mortality risk is small and there’s not much to change perioperatively, “Dr. Sullivan said.

The goal then is to prevent patients from decompensating. Dr. Sullivan avoids giving her compensated cirrhotic patients benzodiazepenes and managing fluids to avoid overload, and to minimize portal hypertension and ascites.

If a compensated patient becomes decompensated, the one-year mortality risk increases to 20 percent. If a patient is even mildly decompensated preoperatively, it warrants asking whether the surgery should be done at the proposed institution.

“It has nothing to do with the skill of the surgeon. Mortality risk increases with the severity of decompensation,” Dr. Sullivan said.

To further optimize patient outcomes and reduce the risk of mortality, anesthesiologists also should evaluate a patient’s Child-Turcotte-Pugh (CTP) and Model for End-Stage Liver Disease (MELD) scores. Patients with a CTP Class B or a MELD score of greater than 8 have an increased risk of mortality. The MELD score is extremely dynamic, Dr. Sullivan said.

“The number you should use should be within the last 48 hours,” Dr. Sullivan said.

To prevent complications in cirrhotic patients undergoing elective surgery, it’s important to avoid overly relying on the INR to assess bleeding and clotting risk during surgery because of its lack of sensitivity and specificity. Similarly, an echocardiogram can miss cirrhotic cardiomyopathy.

“Many cardiologists will look at a patient’s echo and report an athletic heart,” Dr. Ramsay said. “EKG, with an ejection fraction of less than 55 percent, is a better indicator for cirrhotic cardiomyopathy.”

Managing cirrhotic patients undergoing elective surgery takes a tailored, multidisciplinary approach that allows anesthesiologists to collaborate with surgeons to optimize long-term outcomes.

“In this patient population, your expertise and knowledge have everything to do with how patients do in a week, a month or a year,” Dr. Sullivan said. “We need to own that.”

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