From the Guidelines
Anesthetic management for a 6-year-old male (23kg) with stable liver failure secondary to biliary atresia undergoing pre-patellar bursitis washout requires careful consideration of hepatic function and medication metabolism, and I recommend a balanced anesthetic approach with careful drug selection and dosing, as outlined in the most recent guidelines for perioperative care for liver surgery: enhanced recovery after surgery (ERAS) society recommendations 2022 1.
Key Considerations
- Preoperatively, assess coagulation status (PT, INR, platelets), liver function tests, and electrolytes, and consider vitamin K administration (0.3mg/kg IV) if coagulation is impaired, as recommended by the American Association for the Study of Liver Diseases, American Society of Transplantation and the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition 1.
- For induction, use reduced doses of propofol (1-2mg/kg) or consider etomidate (0.2-0.3mg/kg) as it has minimal hepatic effects, and maintain anesthesia with sevoflurane (MAC 0.7-1.0) as it undergoes minimal hepatic metabolism compared to other volatile agents.
- For analgesia, use fentanyl (1-2mcg/kg) or hydromorphone (0.01-0.02mg/kg) titrated to effect, avoiding morphine due to its hepatic metabolism, and consider regional anesthesia with an ultrasound-guided adductor canal block using 0.25% ropivacaine (0.5ml/kg) to provide excellent postoperative pain control while minimizing systemic opioid requirements.
- Avoid medications requiring significant hepatic metabolism such as midazolam, and maintain normothermia, normal blood glucose, and adequate hydration with isotonic fluids at 4-6ml/kg/hr.
- Postoperatively, use acetaminophen cautiously at reduced doses (10mg/kg q6h with maximum daily dose of 40mg/kg) and monitor liver function, as recommended by the ERAS society recommendations 2022 1.
Additional Recommendations
- Consider preoperative fasting of 2 hours for liquids and 6 hours for solids before anesthesia, and carbohydrate loading the evening before liver surgery and 2 hours before induction of anesthesia, as recommended by the ERAS society recommendations 2022 1.
- Avoid long-acting anxiolytic drugs, particularly in the elderly, and consider short-acting anxiolytics in selected cases to facilitate regional anesthesia prior to general anesthesia induction, as recommended by the ERAS society recommendations 2022 1.
- Maintain perioperative normothermia using multimodal temperature management, and consider postoperative artificial nutrition and early oral intake, as recommended by the ERAS society recommendations 2022 1.
From the Research
Considerations for Anaesthesia in a 6yo Male with Stable Liver Failure
When administering anaesthesia to a 6-year-old male with a history of stable liver failure secondary to biliary atresia, several factors must be considered:
- The patient's liver function and its potential impact on drug metabolism and clearance 2, 3
- The risk of hypotension and hypovolemia, which can exacerbate liver failure 2
- The potential for multiple organ involvement and the need for a holistic approach to care 3
- The importance of a multidisciplinary approach to diagnosis and management, including surgical intervention and histopathologic evaluation 4
Anaesthetic Management
The anaesthetic management of this patient should take into account the following:
- Careful selection of anaesthetic agents and dosages to minimize the risk of liver toxicity and ensure adequate clearance 5
- Close monitoring of the patient's haemodynamic status and liver function during the procedure 2, 3
- Consideration of the potential for post-operative complications, such as bleeding or infection, and the need for prompt treatment 4, 6
Pre-Operative Evaluation
A thorough pre-operative evaluation should include: