Anesthesia for Liver diseased and renal disease

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Anesthesia for Liver diseased and renal disease

• Dr. Bundit Chintanapramote

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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)

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Functions of the Liver

• Metabolic
• Glucose metabolism
• Protein metabolism
• Lipid metabolism
• Protein synthesis
• Coagulation factors II V VII X
• Albumin
• Pseudo cholinesterase

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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)

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Preoperative evaluation

1. Respiration system
2. Cardiovascular system
3. Gastrointestinal system
4. Renal system
5. CNS system
6. Hematological system
7. Metabolic and electrolyte

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Preoperative assessment

• CVS
• 70 develop hyperdynamic circulation
• increase cardiac output (CI and HR)
• decrease SVR
• normal or low BP (BP COXSVR)
• rhythm disturbance from electrolyte imbalance

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Preoperative assessment

• 1. CVS
• increase heart rate
• down regulation of adrenergic receptors
• down regulation of baroreceptors
• Alcoholic cardiomyopathy

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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

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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
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Preoperative assessment

• Hepatorenal syndrome
• severe liver disease
• diminish effective circulatory volume
• neurohumonal factors
• normal histology
• urine Na lt 10 mEg/L
• Acute tubular necrosis
• Prerenal azotemic

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Hepatorenal syndrome

• Major criteria
• Chronic or acute hepatic disease and liver
  failure with portal hypertension
• Serum creatinine level gt 1.5 mg/dl or 24 hr
  cretinine clearance lt 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 lt 500 mg/day and no ultrasonograhic
  evidence of renal tract or parenchyma disease

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Hepatorenal syndrome

• Minor criteria
• Urine Volume lt 500 ml/day
• Urine Sodium lt 10 mEg/L
• Urine Osmolality greater than plasma osmolality
• Urine red blood cell count lt 50 per high power
  field
• Serum sodium lt 130 mEg/L

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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

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Preoperative assessment
4. Hematologic system 1.1 anemia
reduce synthesis intake, macrocytic anemia
reduce life span MAHA
hypersplenism increase loss
esophageal varices
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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
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Preoperative assessment
5. CNS hepatic encephalopathy
ammonia level 90 mortality GABA
receptor cerebral edema
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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
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Surgical risk assessment Childs classification
as modified by Pugh
Mortality Minimal (lt 5) Modest (5-50) Marked (gt 50)
Bilirubin (mg/dl) lt 2 2-3 gt 3
Albumin (g/dl) gt 3.5 3-3.5 lt 3
PT (seconds prolonged) 1-4 (INR lt 1.7) 4-6 (INR 1.7-2.3) gt 6 (INR gt 2.3)
Ascites None Moderate Marked
Encephalopathy (p134) None Grades 1and 2 Grades 3and4
4Nutrition Excellent Good Poor
PT prothrombin time. INR international
normalised ratio.
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Effects of anesthesia on the liver

• Liver blood flow
• ? Ventilation spontaneous, IPPV, PEEP
• ? Hypoxia vasoconstrict, sympathetic
  stimulation
• ? Carbon dioxide normocarbia
• ? Surgery
• ? Drugs Volatile anesthetics
• IV anesthetic
• regional block

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Effects of anesthesia on the liver
2. Liver blood flow ? Volatile anesthetic
halothane hepatitis ? IV anesthetic agents
no effect
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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
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Anesthetic agents
3. NMB ? Prolong effect pancuronium, vecuronium,

rocuronium ? Suxamethonium ?
Suitable for tracium, cisatracurium 4.
Opioids ? avoid morphine alfentanyl
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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
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Anesthetic drugs in liver failure
Drugs safe in liver failure Drugs to be used with caution (may Need reduced dosage) Drugs contraindicated in liver failure
Premedication Lorazepam Midazolam, diazepam
Induction Propofol, thiopental, etomidate
Maintenance Desflurane, sevoflu-rane, isoflurane, nitrous oxide Enflurane Halothane (possibly)a
Muscle relaxants Atracurium, cisatracurium Pancuronium, vecuronium, suxamethonium
Opioids Remifentanil Fentanyl, alfentanil, morphine, pethidine
Analgesics Paracetamol NSAIDs, lidocaine, bupivacaine
a Halothane has been rarely reported to cause
hepatitis (see p143).
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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 Gilberts syndrome
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Renal disease Sign and Symptoms of TURP syndrome

• Cardiopulmonary
• Hypertension
• Bradycardia
• Dysrhythmia
• Respiratory distress
• Cyanosis
• Hypotension
• Shock
• Death

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• Hematologic and renal
• Hyperglycinemia
• Hyperammonemia
• Hyponatremia
• Hypoosmolality
• Hemolysis / anemia
• Acute renal failure
• Death

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• Central nervous system (CNS)
• Nausea / vomiting
• Confusion / restlessness
• Blindness
• Twitches / seizures
• Lethargy / paralysis
• Dilated / non reactive pupils
• Coma
• Death

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Sign and Symptoms of acute hyponatrcmia
Serum Na (meq/L) CNS EKG pattern
120 Drowsy Restlessness Wide QRS complex
115 Disoriented Nausea, Vomiting Wide QRS complex ST segment eleviated
110 Convulsion Coma Ventricular tachycardia Ventricular fibrillation
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Risk factors for perioperative ARF
Pre-existing problem Renal compromise, diabetes, Advanced age
Perioperative Sepsis, hypotension/hypovolaemia, dehydration
Drugs Nephrotoxins antibiotics, NSAIDs, ACE inhibitors, lithium, chemotherapy agents, Radiological contrast media
Trauma Rhabdomyolysis (myoglobinaemia from Crush injuries)
Surgery Biliary surgery in the presence of obstruc-tive jaundice (hepatorenal syndrome) Renal and abdominal vascular surgery
Intra-abdominal hypertension Any cause of abdominal distension
Urinary obstruction
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Anesthetic drugs in chronic renal failure
Drugs safe in CRF Drugs safe in limited or reduced doses) Drugs contra-indicated in CRF
Premedication Lormetazepam, midazolam, temazepam
Induction Propofol, thiopental, etomidate Ketamine
Maintenance Isoflurane, desflurane, halothane, propofol sevoflurane Enflurane
Muscle relaxants Suxamethonium, atracurium, cisatracurium vecuronium, rocuronium Pancuronium
Opioids Alfentanil, remifentanil Fentanyl, morphine Pethidine
Local anaesthetics Bupivacaine, lidocaine
Analgesics Paracetamol NSAIDs