Liver Cirrhosis Patient Posted for Exploratory Laparotomy

Introduction

1. Preoperative Assessment and Risk Stratification

A. History and Clinical Evaluation

• Bleeding tendency, previous variceal haemorrhage
• Ascites, pedal oedema, hepatorenal syndrome
• Encephalopathy grade, cognitive status
• Nutritional status, recent weight loss
• Current medications (diuretics, lactulose, rifaximin, beta-blockers)

B. Risk Stratification Tools

• Class A (5-6): 10% operative mortality - surgery generally acceptable
• Class B (7-9): 17-30% operative mortality - proceed with caution
• Class C (10-15): 60-80% operative mortality - elective surgery contraindicated; consider liver transplantation first

• MELD <11: Low postoperative mortality; acceptable surgical risk
• Each MELD point up to 20 = ~1% additional 30-day mortality
• Each MELD point above 20 = ~2% additional 30-day mortality
• MELD ≥25: ~50% 30-day mortality after abdominal surgery
• MELD ≥20: Elective surgery is contraindicated until after liver transplantation

C. Investigations

• Full blood count - anaemia, thrombocytopaenia (due to hypersplenism)
• Coagulation screen: PT/INR, aPTT, fibrinogen
• Thromboelastography (TEG) or thromboelastometry (ROTEM) - viscoelastic testing better reflects true bleeding risk than INR alone

• LFTs: bilirubin, transaminases (AST, ALT), ALP, GGT
• Albumin, total protein
• Renal function: urea, creatinine, electrolytes (hyponatraemia common)
• Blood glucose (risk of hypoglycaemia - depleted glycogen stores)
• Ammonia level (if encephalopathy suspected)

• ECG - arrhythmias, QTc prolongation
• Echocardiography - rule out cirrhotic cardiomyopathy, systolic/diastolic dysfunction, hepatopulmonary syndrome, portopulmonary hypertension

• CXR - pleural effusion (hepatic hydrothorax), cardiomegaly
• SpO2, ABG - hepatopulmonary syndrome causes hypoxaemia via intrapulmonary shunting

• Ultrasound abdomen with Doppler - assess portal hypertension, splenomegaly, ascites, hepatic veins
• Diagnostic paracentesis if ascites present - rule out spontaneous bacterial peritonitis (SBP)

2. Preoperative Optimisation

A. Nutrition

• Protein-calorie malnutrition is near-universal in cirrhosis
• Target protein intake: 1.0-1.5 g/kg/day
• High carbohydrate, high lipid diet; late-evening carbohydrate snack
• Vitamin supplementation especially Vitamin B1 (thiamine) in alcoholics
• Nutritional support (enteral/parenteral) if severely malnourished

B. Coagulopathy

• Do NOT routinely transfuse FFP to correct INR - INR does not reliably predict bleeding risk in cirrhosis (both pro- and anticoagulant factors are deficient)
• Use viscoelastic testing (TEG/ROTEM) to guide targeted blood product replacement
• Platelet count <50,000/µL: consider platelet transfusion for major surgery
• Vitamin K administration if deficiency suspected
• Cryoprecipitate for low fibrinogen (<1.5 g/L)
• Avoid over-correction - cirrhotic patients also carry a risk of thromboembolic complications

C. Ascites

• Large-volume paracentesis with IV albumin replacement (6-8 g albumin per litre of ascites drained) preoperatively
• Salt restriction and diuretics (spironolactone ± furosemide)
• Treat SBP if present with antibiotics before surgery
• Large-volume ascites causes diaphragmatic splinting, respiratory compromise, and aspiration risk

D. Hepatic Encephalopathy

• Identify and treat precipitating factors (infection, GI bleed, electrolyte disturbance, constipation)
• Lactulose to maintain 2-3 soft stools/day
• Rifaximin (preferred if bowel surgery planned - less bowel distension than lactulose)
• Avoid hepatotoxic drugs and sedatives

E. Renal Function

• Rule out hepatorenal syndrome (HRS)
• Avoid nephrotoxic drugs: NSAIDs, aminoglycosides, iodinated contrast
• Volume status optimisation
• If HRS type 1: terlipressin + albumin; consider TIPS

F. Cardiovascular

• Treat portal hypertension: non-selective beta-blockers (propranolol, carvedilol) for variceal prophylaxis - do not stop perioperatively
• Address portopulmonary hypertension (a contraindication to surgery if severe)
• TIPS may be considered in selected cases of severe portal hypertension to reduce operative bleeding risk, but risks worsening encephalopathy

3. Intraoperative Management

A. Monitoring

• Standard monitors: ECG, SpO2, ETCO2, temperature
• Invasive arterial line (radial artery) - mandatory due to haemodynamic instability, need for serial ABGs and labs
• Central venous access - for drug infusions, vasopressors, CVP trend (though CVP has limitations in predicting fluid responsiveness)
• Urinary catheter with hourly urine output monitoring
• TEG/ROTEM for real-time coagulation guidance
• TEE - can be used for haemodynamically unstable patients; use with caution if recent variceal banding (avoid transgastric views to minimise risk)
• Avoid pulmonary artery catheter unless severe pulmonary hypertension

B. Anaesthetic Technique

• Reduce doses of all intravenous induction agents - hypoalbuminaemia increases free drug fraction
• Propofol: acceptable but reduce dose; associated with hepatic artery vasodilation
• Ketamine: use with caution (increases portal pressure)
• Avoid etomidate (adrenal suppression in prolonged use)
• Succinylcholine: safe in standard doses; pseudocholinesterase levels may be low, causing prolonged block
• Rocuronium/atracurium: rocuronium is hepatically metabolised - prolonged action; cisatracurium (Hofmann elimination) or atracurium are preferred muscle relaxants as they do not depend on hepatic or renal elimination

• Sevoflurane is the volatile agent of choice - minimal hepatic metabolism, no hepatotoxic metabolites
• Avoid halothane (halothane hepatitis) and enflurane (significant hepatic metabolism)
• Isoflurane reduces hepatic arterial and portal venous blood flow less than other agents at equipotent doses
• Total IV anaesthesia (TIVA) with propofol infusion is acceptable; monitor for accumulation with prolonged infusion
• Avoid N2O in bowel surgery and when there is significant ascites (bowel distension)

• Fentanyl or hydromorphone preferred - not metabolised to active compounds
• Avoid morphine - extensively hepatically metabolised, active metabolites (morphine-6-glucuronide) accumulate causing prolonged sedation, especially with coexisting renal failure
• Tramadol has favourable hepatic metabolism but lowers seizure threshold

C. Haemodynamic Management

• Characterised by hyperdynamic circulation (high CO, low SVR), blunted contractile response to stress
• Patients become profoundly hypotensive on induction due to vasodilation that the heart cannot compensate
• Vasopressors (noradrenaline is preferred) should be anticipated from induction
• Maintain MAP >65 mmHg to preserve hepatic perfusion

• Restrict crystalloid - avoid expanding interstitial volume and re-accumulating ascites
• Use albumin as preferred colloid in cirrhotics
• Avoid saline - risk of hyperchloraemic acidosis; balanced solutions (Hartmann's/PlasmaLyte) preferred

• Target Hb 7-8 g/dL in stable patients (restrictive strategy - overtransfusion increases portal pressure and variceal bleeding risk)
• Guided by TEG/ROTEM rather than routine correction of INR/PT

D. Positioning and Surgical Considerations

• Intra-abdominal varices, peristomal/umbilical varices pose major surgical bleeding risk
• Have adequate IV access, blood products cross-matched and available in theatre
• Cell salvage may be considered where appropriate
• Avoid prolonged hypotension - worsens hepatic ischaemia
• Drain ascites in a controlled manner at start of surgery - avoid rapid large-volume drainage causing haemodynamic collapse

4. Postoperative Management

A. Analgesia

• Paracetamol: safe at ≤2 g/day (maximum) - do NOT withhold entirely; a common misconception
• NSAIDs: contraindicated - impair renal blood flow, worsen hepatorenal syndrome
• Fentanyl/hydromorphone: preferred opioids
• Morphine: avoid, especially with renal impairment
• Epidural analgesia: relative contraindication due to coagulopathy; use only if coagulation corrected and benefits outweigh risks

B. Monitoring for Complications

C. Hepatic Encephalopathy Prevention

• Resume lactulose/rifaximin
• Early nutrition - avoid prolonged starvation
• Avoid benzodiazepines for sedation (accumulate due to reduced hepatic clearance; precipitate encephalopathy)
• Short-acting benzodiazepines (midazolam) if essential for sedation

D. Drug Considerations Postoperatively

• Reduce doses and extend dosing intervals for all hepatically metabolised drugs
• Avoid accumulation with repeated opioid dosing
• Supplement with polyethylene glycol for bowel regularity
• Restart diuretics and beta-blockers as soon as oral intake is adequate

5. Specific Considerations for Exploratory Laparotomy

1. Intraoperative haemorrhage from abdominal varices, adhesions, or coagulopathy - have blood products and cell salvage ready
2. Wound healing - hypoalbuminaemia, malnutrition, and impaired immune function increase risk of wound dehiscence and infection
3. Ascites leak through wound - contributes to wound dehiscence and infection; drain ascites before closure
4. Abdominal compartment syndrome risk if ascites re-accumulates rapidly postoperatively
5. Hepatorenal syndrome triggered by hypotension, blood loss, sepsis - most feared complication postoperatively

Summary Table

• Barash, Cullen, and Stoelting's Clinical Anesthesia, 9e - Chapter 46: Liver Disease
• Miller's Anesthesia, 10e - Chapter 29: Box 29.9 / Postoperative Management
• Sabiston Textbook of Surgery, 22e - Chapter 51: Liver Disease and Surgery
• Fischer's Mastery of Surgery, 8e - Hepatobiliary Risk Assessment