Anesthesia for Liver diseased
and renal disease
Dr. Bundit Chintanapramote
Anatomy
: Liver : wt 1500 gm (2% of BW)
: Blood flow 150 ml/100 gm/min
(1500 ml/min, 25% of cardiac output)
: Portal blood flow 75%
(Oxygenation 50%)
: Hepatic artery blood flow 25%
(Oxygenation 50%)
Functions of the Liver
1. Metabolic
• Glucose metabolism
• Protein metabolism
• Lipid metabolism
2. Protein synthesis
• Coagulation factors II V VII X
• Albumin
• Pseudo cholinesterase
Functions of the Liver
3. Drug metabolism
• reduce albumin
• increase volume of distribution
• impair phase I reaction
4. Bilirubin formation and excretion
• Hyperbilirubinemia (renal dysfunction
replace binding site for drugs)
Preoperative evaluation
1.
2.
3.
4.
5.
6.
7.
Respiration system
Cardiovascular system
Gastrointestinal system
Renal system
CNS system
Hematological system
Metabolic and electrolyte
Preoperative assessment
1. CVS
• 70% develop hyperdynamic circulation
• increase cardiac output (CI and HR)
• decrease SVR
• normal or low BP (BP = COXSVR)
• rhythm disturbance from electrolyte
imbalance
Preoperative assessment
1. CVS
• increase heart rate
• down regulation of adrenergic
receptors
• down regulation of baroreceptors
• Alcoholic cardiomyopathy
Preoperative assessment
2. Respiratory system
• Restrictive lung disease from ascites or
pleural effusions frequently responds to
fluid removal
• Intrapulmonary shunts (hypatopulmonary
syndrome (HPS) hypoxia occurring in the
absence of ascites or intrinsic lung disease
• Ventilation – perfusion (V/Q)
abnormalities
Preoperative assessment
3. Renal system
• Salt retention due to secondary hyperaldosteronism
Decrease effective circulatory volume
Decrease renal blood flow
Increase aldosterone
Na retention, K depletion, metabolic acidosis
Preoperative assessment
• Hepatorenal syndrome
: severe liver disease
: diminish effective circulatory volume
: neurohumonal factors
: normal histology
: urine Na < 10 mEg/L
• Acute tubular necrosis
• Prerenal azotemic
Hepatorenal syndrome
Major criteria
• Chronic or acute hepatic disease and liver failure with
portal hypertension
• Serum creatinine level > 1.5 mg/dl or 24 hr cretinine
clearance < 40 ml/min
• Absence of shock, ongoing bacterial infection, recent
use of nephrotoxic drugs, excessive fluid or blood loss
• No sustained improvement in renal function after
volume expansion with 1.5 L isotonic saline solution
• Proteinuria < 500 mg/day and no ultrasonograhic
evidence of renal tract or parenchyma disease
Hepatorenal syndrome
Minor criteria
• Urine Volume < 500 ml/day
• Urine Sodium < 10 mEg/L
• Urine Osmolality greater than plasma
osmolality
• Urine red blood cell count < 50 per high
power field
• Serum sodium < 130 mEg/L
Factor that care precipitate
• Use of nephrotoxic medication (eg.)
nonsteroidal anti-inflammatory drugs)
• Acute gastrointestinal bleeding
• Excessive diuresis
• Excessive large – volume paracentesis
• Infection (eg, spontaneous bacterial
peritonitis sepsis
Preoperative assessment
4. Hematologic system
1.1 anemia
; reduce synthesis – intake, macrocytic anemia
; reduce life span – MAHA
– hypersplenism
; increase loss
– esophageal varices
Preoperative assessment
1.2 coagulopathy
; platelet quantitative and qualitative platelet
defects (splenic sequestration, low levees of
thrombopoietin from liver, sepsis bone marrow
suppression, DIC (consumption)
; Vit K deficiency
; reduce synthesis of coagulation factors
(check PT, PTT), factor VII (T½ 4-8 hr)
; 10% and 20% of patients with end-stage liver
disease show baseline enhanced fibrinolysis
Preoperative assessment
5. CNS
; hepatic encephalopathy
; ammonia level
; 90 % mortality
; GABA receptor
; cerebral edema
Drug handling in liver disease
1. Biotransformation
; phase I reaction – oxidation reduction from
water soluble substance
(halogenated inhalation, BZP, narcotics)
; phase II reaction – conjugation to glucoronide
(propofol, morphine, lorazepam, oxazepam)
2. Protein binding
; reduce albumin
3. Volume of distribution (vd)
; pancuronium
Surgical risk assessment: Child’s classification as modified by Pugh
Mortality
Bilirubin (mg/dl)
Albumin (g/dl)
PT (seconds prolonged)
Ascites
Encephalopathy (p134)
4Nutrition
Minimal
(< 5%)
Modest
(5-50%)
Marked
(> 50%)
<2
2-3
>3
> 3.5
3-3.5
<3
1-4
(INR < 1.7)
None
4-6
(INR 1.7-2.3)
Moderate
>6
(INR > 2.3)
Marked
None
Excellent
PT = prothrombin time.
INR = international normalised ratio.
Grades 1and 2 Grades 3and4
Good
Poor
Effects of anesthesia on the liver
1. Liver blood flow
 Ventilation ; spontaneous, IPPV, PEEP
 Hypoxia ; vasoconstrict, sympathetic stimulation
 Carbon dioxide ; normocarbia
 Surgery
 Drugs
; Volatile anesthetics
; IV anesthetic
; regional block
Effects of anesthesia on the liver
2. Liver blood flow
 Volatile anesthetic
; halothane hepatitis
 IV anesthetic agents
; no effect
Anesthetic agents
1. Premedication
 short acting benzodiazepine : lorazepam, midazolam
 avoid sedative in severe ascites encephalopathy
2. Induction
 normal dose except hepatic encephalopathy
 rapid sequence induction
Anesthetic agents
3. NMB
 Prolong effect pancuronium, vecuronium,
rocuronium
 Suxamethonium
 Suitable for tracium, cisatracurium
4. Opioids
 avoid morphine alfentanyl
Anesthetic agents
5. Inhalation agent
 avoid N2o in severe ascites
 halothane reduce liver blood flow causing
halothane hepatitis
 Isoflurane, sevoflurane, desflurane can be used
safely
Anesthetic drugs in liver failure
Drugs safe in
liver failure
Premedication
Lorazepam
Induction
Muscle
relaxants
Propofol, thiopental,
etomidate
Desflurane, sevoflurane, isoflurane,
nitrous oxide
Atracurium,
cisatracurium
Opioids
Remifentanil
Analgesics
Paracetamol
Maintenance
a
Drugs to be used
with caution (may
Need reduced
dosage)
Midazolam,
diazepam
Drugs
contraindicated
in liver failure
Enflurane
Halothane
(possibly)a
Pancuronium,
vecuronium,
suxamethonium
Fentanyl, alfentanil,
morphine, pethidine
NSAIDs, lidocaine,
bupivacaine
Halothane has been rarely reported to cause hepatitis (see p143).
Causes of postoperative liver dysfunction or jaundice
Bilirubin overload
(haemolysis)
Blood transfusion
Haematoma resorption
Haemolytic anaemia (sickle, cell, prosthetic heart
valve, glucose-6-phosphatase deficiency)
Hepatocellular injury Exacerbation of pre-existing liver disease
Hepatic ischaemia: hypovolaemia, hypotension,
cardiac failure
Septicaemia
Drug-induced (antibiotics, halothane)
Hypoxia
Viral hepatitis
Cholestasis
Intrahepatic (benign, infection, drug-induced,
e.g. cephalosporins, carbamazepine, erythromycin)
Extrahepatic (pancreatitis, gallstones, bile duct
Injury)
Congenital
Gilbert’s syndrome
Renal disease
Sign and Symptoms of TURP syndrome
• Cardiopulmonary
Hypertension
Bradycardia
Dysrhythmia
Respiratory distress
Cyanosis
Hypotension
Shock
Death
• Hematologic and renal
Hyperglycinemia
Hyperammonemia
Hyponatremia
Hypoosmolality
Hemolysis / anemia
Acute renal failure
Death
• Central nervous system (CNS)
Nausea / vomiting
Confusion / restlessness
Blindness
Twitches / seizures
Lethargy / paralysis
Dilated / non reactive pupils
Coma
Death
Sign and Symptoms of acute hyponatrcmia
Serum Na (meq/L) CNS
EKG pattern
120
Drowsy
Restlessness
Wide QRS complex
115
Wide QRS complex
Disoriented
Nausea, Vomiting ST segment eleviated
110
Convulsion
Coma
Ventricular tachycardia
Ventricular fibrillation
Risk factors for perioperative ARF
Pre-existing problem
Perioperative
Drugs
Trauma
Surgery
Intra-abdominal hypertension
Urinary obstruction
Renal compromise, diabetes,
Advanced age
Sepsis, hypotension/hypovolaemia,
dehydration
Nephrotoxins: antibiotics, NSAIDs, ACE
inhibitors, lithium, chemotherapy agents,
Radiological contrast media
Rhabdomyolysis (myoglobinaemia from
Crush injuries)
Biliary surgery in the presence of obstructive jaundice (hepatorenal syndrome)
Renal and abdominal vascular surgery
Any cause of abdominal distension
Anesthetic drugs in chronic renal failure
Drugs safe in CRF
Premedication
Induction
Maintenance
Muscle
relaxants
Opioids
Local
anaesthetics
Analgesics
Lormetazepam,
midazolam, temazepam
Propofol, thiopental,
etomidate
Isoflurane, desflurane,
halothane, propofol
Suxamethonium,
atracurium,
cisatracurium
Alfentanil, remifentanil
Bupivacaine, lidocaine
Paracetamol
Drugs safe in
limited or
reduced doses)
Drugs
contra-indicated
in CRF
Ketamine
sevoflurane
Enflurane
vecuronium,
rocuronium
Pancuronium
Fentanyl, morphine
Pethidine
NSAIDs