What are the anaesthesiology considerations for liver disease?

From the Guidelines

Liver anesthesiology requires careful consideration of medication selection, dosing, and monitoring due to altered drug metabolism and potential for hepatic decompensation, and I strongly recommend following the Enhanced Recovery After Surgery (ERAS) society recommendations for liver surgery. For patients with liver disease, using short-acting agents with minimal hepatic metabolism is crucial whenever possible 1.

Key Considerations

• Propofol is preferred for induction (1-1.5 mg/kg reduced dose) and maintenance (50-150 mcg/kg/min) as it has minimal hepatic metabolism.
• For muscle relaxation, cisatracurium (0.1-0.2 mg/kg) or atracurium are ideal choices as they undergo Hofmann elimination independent of liver function.
• Fentanyl (1-2 mcg/kg) or remifentanil (0.05-0.2 mcg/kg/min) are appropriate opioids due to their short duration.
• Avoid benzodiazepines when possible, but if needed, use reduced doses of midazolam (0.5-1 mg).
• Maintain adequate perfusion pressure to preserve hepatic blood flow, targeting a mean arterial pressure of 65-70 mmHg.
• Close monitoring of coagulation parameters is essential, with thromboelastography preferred when available.
• Maintain normothermia, normoglycemia, and adequate fluid balance, using balanced crystalloids rather than normal saline to avoid hyperchloremic acidosis.
• Multimodal analgesia, including the potential use of intrathecal opiates, is recommended for postoperative pain management 1.
• Early mobilization and scheduled mobilization should be established from the operative day until hospital discharge 1.
• A multimodal approach to postoperative nausea and vomiting should be used, with at least 2 antiemetic drugs such as dexamethasone and ondansetron 1. These considerations are crucial because liver dysfunction affects drug clearance, protein binding, and volume of distribution, while also potentially impairing coagulation, glucose regulation, and acid-base balance, as highlighted in the ERAS society recommendations 1. Careful anesthetic management helps prevent further hepatic decompensation and supports optimal patient outcomes.

From the Research

Liver Anaesthesiology Considerations

• The incidence of chronic liver disease (CLD) is rising, and perioperative mortality and morbidity remains high in this group 2.
• Meticulous preoperative assessment and carefully planned anaesthetic management are vital in improving outcomes in patients with liver disease undergoing surgery 2, 3, 4, 5.
• The Child-Pugh-Turcotte scale and model for end-stage liver disease (MELD) score are commonly used scoring systems in preoperative risk assessment, but new MELD-based indices and novel scoring systems may offer better prognostic value 2, 4.

Anaesthetic Management

• Propofol and new inhalational agents (sevoflurane, desflurane) are recommended hypnotic agents for patients with liver disease 2, 3.
• The titration of opiates in the perioperative period is recommended due to their altered metabolism in patients with liver disease 2.
• Regional anesthesia may be used in patients with advanced liver disease, with lower drug dosages and less systemic effects 3.
• General anesthesia with inhalation agents (isoflurane, desflurane, or sevoflurane) and small doses of fentanyl can be considered a reasonable regimen 3, 4.

Perioperative Care

• Close haemodynamic monitoring and admission to a critical care area should be considered for patients with liver disease undergoing anaesthesia 2.
• Pre-operative optimization should include control of ascites, correction of electrolyte imbalance, improving renal dysfunction, cardiorespiratory assessment, and correction of coagulation 4.
• Intra-operatively, safe anesthetic agents like isoflurane and propofol with avoidance of hypotension are advised, and nonsteroidal anti-inflammatory drugs (NSAIDs) and benzodiazepines should be avoided 4.

Specific Anaesthetic Regimens

• The use of propofol combined with remifentanil anesthesia may contribute to the balance of NO/ET-1 and the inhibition of inflammatory factors during hepatectomy operation in patients with liver cirrhosis, and help to protect liver function 6.