From the Guidelines
In patients with hepatic failure, it is crucial to avoid anesthetic agents that rely heavily on hepatic metabolism or may exacerbate liver dysfunction, and instead, opt for agents with minimal hepatic or renal metabolism, such as propofol, which has no active metabolites 1. When considering anesthesia for patients with liver failure, several factors must be taken into account to minimize morbidity, mortality, and improve quality of life.
Key Considerations
- Hepatic metabolism: Agents that undergo significant hepatic metabolism should be avoided or used with caution.
- Renal metabolism: Drugs with minimal renal metabolism are preferable.
- Potential for hepatotoxicity: Agents known to cause liver damage should be completely avoided.
Recommended Anesthetic Agents
- Propofol: A logical choice for induction of anesthesia due to its minimal hepatic metabolism and lack of active metabolites 1.
Agents to Avoid or Use with Caution
- Halogenated inhalational anesthetics: While desflurane and sevoflurane are preferred due to minimal hepatic metabolism, other agents like halothane should be avoided due to hepatotoxicity concerns.
- Intravenous anesthetics: High or repeated doses of thiopental and ketamine should be avoided due to reduced clearance in liver failure.
- Opioids: Meperidine should be avoided due to the risk of normeperidine accumulation and seizures; instead, use fentanyl, sufentanil, or remifentanil.
- Muscle relaxants: Long-acting agents like pancuronium and vecuronium should be avoided in favor of cisatracurium or atracurium, which undergo Hofmann elimination independent of liver function.
- Benzodiazepines: Should be used sparingly with reduced dosing to avoid precipitating or worsening hepatic encephalopathy.
From the FDA Drug Label
- 6 Drug-Induced Liver Injury Ketamine administration is associated with hepatobiliary dysfunction (most often a cholestatic pattern), with recurrent use (e.g., misuse/abuse or medically supervised unapproved indications).
- Ketamine should be avoided or used with caution in patients with hepatic (liver) failure due to the risk of hepatobiliary dysfunction.
- Patients receiving ketamine should have baseline LFTs obtained, including alkaline phosphatase and gamma glutamyl transferase, and be monitored at periodic intervals during treatment 2.
From the Research
Anesthetic Agents to Avoid in Hepatic Failure
- Methoxyflurane is an anesthetic agent that should be avoided in patients with hepatic failure, as it can cause high-output renal failure due to its metabolite, inorganic fluoride 3.
- Halothane is another agent that may be problematic, as it can cause liver damage through an abnormal metabolite produced via an alternate pathway with induced enzyme activity 3.
Recommended Anesthetic Agents
- Propofol and new inhalational agents (sevoflurane, desflurane) are recommended as hypnotic agents in patients with liver disease 4.
- Remifentanil may be effective in anesthetic management for patients with renal failure and liver dysfunction undergoing hepatectomy due to its unique mode of metabolism 5.
- Regional anesthesia, such as epidural anesthesia, may be used in patients with advanced liver disease, with lower drug dosages and less systemic effects 6.
Considerations for Anesthetic Management
- Meticulous preoperative assessment and carefully planned anesthetic management are vital in improving outcomes in patients with liver disease undergoing surgery 4.
- The titration of opiates in the perioperative period is recommended due to their altered metabolism in patients with liver disease 4.
- Close haemodynamic monitoring and admission to a critical care area should be considered in the perioperative management of patients with liver disease 4.