End Stage Liver Disease 

 

 

Considerations 

 

  • Airway:

    • Aspiration risk due to ↑ gastric volume

    • Friable/edematous tissues

  • Multiorgan dysfunction:

    • CNS: encephalopathy

    • Cardiovascular: hyperdynamic circulation (↑ cardiac output, ↓ SVR), cardiomyopathy, portopulmonary HTN

    • Pulmonary: hypoxemia (intrapulmonary AV shunting, V/Q mismatch); restrictive lung physiology (ascites & pleural effusions)

    • GU: hepatorenal syndrome/renal failure

    • GI: U/LGIB from varices & AVM’s

    • Hematology: coagulopathy (↓ platelets, ↓ clotting factors, ↑ fibrinolysis) & immunodeficiency

    • Endocrine: hypoglycemia, hyponatremia, lactic acidosis

  • Etiology/associated conditions:

    • Viral (e.g. hepatitis)

    • Drugs (e.g. alcohol, acetaminophen)

    • Autoimmune (α-1-antitrypsin deficiency)

    • Hemochromatosis

  • Altered drug pharmacology (↑ volume of distribution, ↓ hepatic clearance, ↓ protein binding)

  • Altered fluid physiology:

    • Total body water excess (ascites) with intravascular volume depletion

    • Low albumin state

  • ​Reconsider elective surgery in very high risk patients (child-pugh class C or MELD > 20)

 

 

Goals

 

  • Identify & optimize multisystem complications

  • Avoid elective or non-emergent surgery in acute liver dysfunction

  • Pre-operative correction of coagulopathy & hypovolemia

  • Consider draining ascites to optimize respiratory mechanics

  • Anticipate fluid shifts & major blood loss

  • Appropriate use of hepatically-metabolized drugs

  • Universal precautions to prevent viral transmission

 

 

Conflicts

 

  • Need for regional vs. coagulopathy

  • High risk patients vs. elective surgery 

  • Pulmonary hypertension vs. laparoscopy 

 

 

Massive Variceal Bleed 

 

  • Emergency situation 

  • Needs emergent airway management with RSI, 2 suctions 

  • Massive hemorrhage: give blood products as indicated, reverse coagulopathy, call massive tranfusion protocol 

  • Pharmacologic:

    • Vasopressin 0.4 unit bolus followed by an infusion of 0.4 to 1 units/min

    • Ocreotide: 50 mcg bolus, then 50 mcg/hr infusion 

  • Balloon tamponade: blakemore (minnesota) tube 

  • Endoscopic management of varices 

  • TIPS if endoscopic management fails