DOA of vecuronium 1 Zone 1>3 Half life is 36hrs Half life is
18hrs N.Value0 35IU/L N.valueO 45 IU/L Cytosol and mitochondria
Cytosol Non specific Relatively liver specific Aspartate
transaminase Alanine transaminase 35. Examples for raised ALT
&AST
- Minor< 100 IU Chronic hepatitis B/ C
- Moderate 100-300IU Alcoholic hepatitis
- Exacerbation of chronic viral hepatitis
- plus all the above condition
36.
- Marked> 300 IU Drugs and toxins
- Acute exacerbation of chronic
- Extrahepatic cholestasis with
- Eventhough it is a marker ofhepatocellular necrosis, the
degree
- of elevation does not correlate with the extent of
necrosis.(no
Examples for raised ALT &AST 37. Aminotransferace(ALT
&AST)
- AST/ALT ratio may be of value in differential diagnosis.
-
- 2-4 (alcoholic liver disease)
- Increasing PT is a ominuos sign in patient with acute
- hepatocellular disease (impending hepatic failure).
- Prothrombin time in contrast to s.albumin is a useful
- prognostic indicator in acute hepatocellular disease.
- ( as half life of CF is short IC to albumin)
42. Prothrombin time
- Mild moderate hepatic disease may not be detected by PT as
- only 30% ofCF is neededfor maintaining haemostasis.
- Cholestatic jaundice -correction of PT by atleast 30%within
24
- hr of vit k administrationsuggest hepatic synthetic
function
- is intact ( prolonged PT due to vit k deficiency alone).
- Prolonged PT >5sec above control not corrected by vitamin
k
- administration is a poor prognostic sign ( in both acute
and
- INR is a better indicator than PT because it is a
standardized
- value and is not subjected to lab variability as PT.
43. Albumin
- Normal value 3.5 to 5.5gm/dl.
- Blood level depends uponrate of
synthesis(10-15gm/day),rate
- of degradation and plasma volume.
- Half life of serum albumin is about 21 days.
- Not a good indicator of acute hepatic dysfunction because
of
- slow turnover ( long half life with 4% degredation per
day).
44. Albumin
- In patients with hepatitis, albumin< 3gm/dl should
- raise the possibility of chronic liver disease.
- Decreasing albumin level in patient with chronic liver
- disease indicates worseningof liver function in the
- absence of other causes of hypoalbuminemia.
- As long as albumin level is more than 2.5gm per dl,
- free or unbound fraction of the drug wont be
45. Bilirubin
- Normaltotal bilirubin value is < 1mg/dl.Out of
these,upto
- 0.3mg is conjugated bilirubin.
- Unconjucated bilirubin is toxic for neuronal cell whereas
the
- conjucated bilirubin is responsible for renal dysfunction
in
- patient with obstructive jaundice.
- Bilirubin value rarely exceeds 6mg/dl in Haemolytic
anaemia.
- Intrahepatic cholestasis to cause rise in bilirubin, drainage
of
- bile in >75% parenchymashould be blocked.
46. Bilirubin
- In choledocholithisis caused by CBD stone,the bilirubin
valuerarely
- exceeds 10mg/dl.Sepsis or renal failureshould be excluded if
the bn
- exceeds30mg/dl in patient with CBD stone.
- In cholestatic jaundice due to malignancy, the bilirubin value
is >10mg but
- Common bile duct obstruction if persist for more than 30 days
will result in
- liver damage and can lead to the developmentof cirrhosis.
- Serum bilirubin will take atleast 1-2 weeks to return to normal
following
- the reliefof obstruction ( half life of delta bn is
2weeks).
47. Antibodies in liver disease Chronic hep C & Type 11
autoimmune hepatitis Anti LKM 1 Chronic hepatitis D Anti LKM3 Drug
induced chr hepatitis Anti LKM2 Type 1 A.I. Hepatitis Antinuclear
antibody Prm sclerosing cholangitis P - ANCA Primary
biliarycirrhosis AntimitochondrialAB 48. Liver biopsy
- Gold standard for evaluation of patient with chronic liver
disease . Liver
- # Diagnosis of various chronic liver disease.
- #Assessing the severity(grade) and stage of liver
- #Predicting the prognosis and
- # monitoring the response to treatment.
49. Histological activity index (knodell Ishak score)
50. Normal LFT Values 14mg/dayUrine urobilinogen11 64IU/LGG
Transpeptidase 1 18IU/L 5 Nucleotidase90 300 IU/L (6-16%) Lactate
dehydrogense 35 100 IU/l Alkaline phosphatase035IU/L
Aminotransferases40 280 mg/day Stercobilinogen0.3-1mg/dl (DB
0.1-0.3) Total bilirubin 51. Normal LFT values 25-35 seconds
Partial thromboplastin Time 11-14 seconds Prothrombin time
1-1.3International N ratio 1080 micg/dl Plasma Ammonia 175 400mg/dl
S.Fibrinogen 2.0 3.5 gm/dlS.globulin 3.5 5.5 gm/dl S.Albumin 52.
Clinical presentation
- Asymptomatic patient with abnormal LFT
- Acute hepatitis/Acute liver failure
- Cirrhosis(compensated & decompensated)
- Obstructive jaundice(Benign & malignant)
53. Asymptmatic patient with abnormal Liver function tests
- Biochemical screening of healthy asymptomatic
- people has revealed thatupto 6% have abnml
- liver enzyme level but the prevalance of liver
- disease in the Gen population is around 1%.
- Liver test must always interpretated along with
- careful history and examination as well as to
- confirm each abnormal test with another test.
54. Evaluation of Isolated Raised AST/ALT 55. 56. Evaluation of
Isolated ALT Elevation 57. Asymptomatic patient with abnormal
LFT
- Aminotransferace elavation < 3timesULN is not a
- contraindication for elective surgery if bilirubin is
- Liver ALP < 3times ULN is not a C/I for elective
- surgery if bilirubin is within normal limits.
- Delay surgery when a patient without any risk factors
- or stigmata of liver disease is having more than one
58. II.Acute hepatitis & liver failure
- Drug induced- Acetiminophen ,Halothane etc
- Acute fatty liver of pregnancy
- Out of these , Drugs is the most common cause of acute
hepatitis/hepatic failure.
- Elective surgery postponed until atleast 30days after the liver
function tests have
- returned to normal because of high perioperative
mortality.
59. Management of acute liver failure
- Airway control should be done with HE 3 or 4.
- Management of raised ICT.
- Management of acid base imbalance.
- Management of electrolyte imbalance/hypoglycemia.
- Management of coagulopathy by vit k & FFP.
- Cardiac support with vasopressors.
- Renal support by Haemofiltration.
- Respiratory support with mechanical ventilation.
- Despite best supportive measures in ICU attached to the
- LT centre, m.rate approaches 50% - 80%.
60. Indication for OLT in acute hepatic failure
- A) Non acetominophen patients
- Any 3 of the following variables
- Non A-nonB hepatitis/Drug induced
- Duration of icterus before HE > 7days.
61. Acute liver failure(cont)
- B) Acetaminophen patients
62. Acute liver failure (cont)
- Paul Brousse hospital criteria
- Hepatic encephalopathy and
- Irreversible brain damage
- Active alcohol or drug abuse
- Advanced cardiopulmonary disease
- Widespread thrombosis of portal/mesentric vein
64. III. Chronic liver disease
- Most common causes of chronic liver disease (in descending
- order)are Chronic hepatitis C
- Primary Biliary cirrhosis
- For chronic hepatitis,Hepatitis c is the most common cause
(Alcoholism for cirrhosis).
65. Chronic hepatitis old classification
- Chronic persistent hepatitis.
- Chronic lobular hepatitis.
- Chronic active hepatitis.
- Chronic active hepatitis in contrast to othertwo subtypes is
a
- prog disorder in which the symptoms range from recurrent
- mild to severe acute exacerbationthateventually progress
66. Chronic hepatitis
- Categorization based only on histopathological features has
been
- replaced by classification that is much moreinformative
based
- Histological activity index.
67. Chronic hepatitis new classification
- CAH Mild to severeMild to cirrhosis
68.
- Chronic hepatitis is said to be active if thereis
- chronic active hepatitis picture on LB
- Aminotransferaces> 2 times ULN.
- Above features should be present for starting medical
Chronic hepatitis B 69. Chronic hepatitis C
- Indication for medical management is like that of
- chronic hepatitis B infection but HCV RNA will be
- HCV more likely to progress
- chronic active hepatitis picture on LB
- Longer duration of infection &
- Immunocompromised states.
70. Alcoholic hepatitis
- Alcoholic hepatitis (acute or acute on chronic) is considered
severe if there
- S.Albumin 5 sec over control
- Alcohol discriminant function >32.
- Alcoholic hepatitis occurs in 10-20% of patient with chronic
alcoholic
- eventhough fatty liver is present in 90% of alcoholics.
71. Autoimmune hepatitis
- Autoimmune hepatitis(acute or acute on chronic) in symptomatic
patient is said
- Aminotransferace>10times ULN.
- S.globulin>2 times ULN in association
- with aminotransferaces>5times ULN.
- Bridging necrosis or multilobular collapse
72. Anaesthetic consideration for Chronic Hepatitis
- Surgical risk correlate with clinical features,biochemical
- features and histological severity of the disease.
- Elective surgery has been reported to be safe in
asymptomatic
- patient with mild-moderate chronic hepatitis.
- Symptomatic and histological severe CH have increased
- surgical risk particularly if hepatic synthetic or
excretory
- function is impaired,PHT if present or bridging/MLN
- necrosis is seen on liver biopsy.
73. Anaesthetic consideration for Chronic Hepatitis
- Chronicalcoholic patient should be abstinent from alcohol
- for atleast 6 mon to undergo elective procedure.
- NASH not a contraindication for elective surgery( >30%
- hepatocytes if contain fat increased mortality)
- Hemochromatosis Evaluate for complication such as
- diabetes,hypothyrodism and cardiomyopathy.
- Wilsons diseaseAntipsychiatric medication hasto be
- continued(surgery can ppt or aggravate neurological
74. IV.Complication of Decompensated cirrhosis
- Thrombocytopenia (qualitative defect
75. Complication of Decompensated cirrhosis(cont)
- Kidney-Hepatorenal syndrome
- CNS-Hepatic encepalopathy
76. Respiratory system
- Ventilation-perfusion mismatch caused by
- impaired HPV,pleural effusion,ascites
- Decreases in diffusion capacity due to intersitial
- oedema,increased ECF & pulmonary HT.
- Incidence of coexisting pulmonary abnormalities
- Hepatic hydrothorax 5 to10%
77. Anaesthetic consideration(R.S)
- Ascites fluid to be drained preoperatively with simultaneous
colloid
- replacement to reduce the splinting effect.
- Coexistent COPD should be optimised & hydrothorax should
be
- Chest tube drain is C/I in hepatic hydrothorax.
- Increased risk for aspiaration(aspiration prophylaxis &
rapid
- Avoid PEEP as far as possible.
- Avoid N2O in patient with COPD & PPH.
- Avoid hypoxia(High inspired 02) & hypocarbia.
- Response of OLT is poor in PPH when compared to HPS.
- Elective postoperative ventilation for major surgery.
- Extubation should be done when the patient is fully awake.
- HPS & hepatic hydrothorax if present is indication for
OLT.
78. Cardiovascular system
- Decreased peripheral vascular resistance.
- Increased cardiac output.
- Increased blood volume but redistributed.
- Low- normal blood pressure with mildly elevated
- Decreased effective circulatorary volume.
- Diminished response to catecholamines.
- Possible cirrhotic & alcoholic cardiomyopathy.
79. Anaesthetic consideration(CVS)
- Pain and light plane of anaesthesia cause decreased HBF
through
- sympathetic nervous system.
- Hypotensive effect of volume depletion is exacerbated because
of
- impaired vasoconstrictor response to catecholamines.
- Redistribution of blood flow from splanchnic as well
asSkeletal
- muscle to central circulation is also impaired.
- Blunted vascular response toexogenous vasopressors and
volume
- Volume assessment and fluid management thro cvp are
oftenmisleading
- as cvp are often elevated despite relative hypovolumia from
increased
- back pressure in the IVC from hepatic enlargement,scarring and
ascites
- induced increased IA pressure.
80. Anaesthetic consideration(CVS)
- PCWP/CVP guided fluid management.
- Low threshold for starting vasopressors as haemorrhage
- Low threshold for volume overload as well as to v.presor
- induced pulmonary oedema.
- Propranolol if used for prophylaxis for GE varices may
- mask the signs of haemorrhage.
- Diuretics should be used with caution in ascites patient
- without oedema (protective effect from intersitial fluid
- wont be there as in patient with oedema).
- Cirrhotic cardiomyopathy if present is an indication for
81. Renal system
- Decreased renal perfusion and GFR.
- Reduction in free water clearance.
- Reduction in sodium excretion.
- Hepatorenal syndrome occurs in 10% of patients with
decompensated
- cirrhosis(100%mortality if OLT not done).
82. Anaesthetic consideration( Kidney)
- Urea falsely low due to decrease hepatic production.
- Bilirubin lowers the measured s.creatinine(underestimation of
renal
- Renal function assesed by inulin ,125 I iothalamate or 51 cr-
EDTA clearance.
- Avoid aggressive diuretic therapy.(Precipitate HE &
HRS)
- Absence of response to spironolactone400mg/day &
furosemide160mg/day
- indicates ascites becomes refractory (consider LVP or
TIPS).
- catheterise evening before surgery and start iv fluids while
fasting @ 1- 2ml/kg/h to
- maintain u.o.of atleast 1ml/kg/hr.( to prevent HRS )
- Avoid morning dose of diuretics before elective surgery.
83. Kidney(cont)
- PCWP/CVP guided I.O.fluid management.
- I.O chart in the P.O.period.
- Avoid hypotension in the P.O.period (meanB.P.10-20% 0f preop
value).
- U.O.of atleast1ml/kg/hr must be achieved in the I.O.period (if
not mannitol
- Avoid NSAID & aminoglycosides in the I.O.period.
- Cirrhotics are also at risk for ATN in the
postoperativeperiod.
- HRS if present is an indication for OLT.
84. Gastrointestinal system
- Development of GE varices & spleenomegaly signify
- the development ofportal hypertension.
- Development of ascites indicates the onset ofhepatic
- GE varices more likely to bleed iftheportal vein
- Prognosis after development of ascites is poor.( 50%
- die within 3years from the onset of diagnosis)
85. Anaesthetic consideration regarding gatroesophageal
varices
- Blood loss in GE varices is haemodynamically sgnft
- and patient should be managed in ICU.
- Propranolol used for prophylaxiswill mask the signs
- or haemodymamic effects of haemorrhage.
- Airway should be protected to preventthe risk from
- Crystalloid and colloid resuscitation along with the
- pharmacological measures such as vasopressin,
- somatostatin or octreotide.
86.
- Alteast 8-12 units of blood should be crossmatched
- during the resucscitation period.
- FFP should be given if the PT is 1.5 times more than
- Care should be taken to prevent volume overload as
- the baseline SBP of most cirrhotics is 85 to 95mmhg
- (volume overload increases hge).
- Endoscopy should be done within 12hrs once the
- patient is haemodynamically stable.
Anaesthetic consideration regarding gatroesophageal varices
87.
- Ascites increases the risk of aspiration by
increasingintra-
- abdominal pressure ( also decreased GITmotility & GERD
- due to hiatal hernia in the cirrhotics).
- PICD can be prevented by concurrent administration of salt
- poor albumin or other colloid.
- Ascites is said to be refractory if there is no response to
the
- maximum dose of furosemide and spiranolactone.
- TIPS should be considered for patient with refractory
ascites
- Tense and refractory ascites should be drained adequately
- before surgery ( significant intra and postop comp.).
Anaesthetic consideration regarding ascites 88. Ascites
Anaesthetic considerationRisk for aspiration False high CVP
Haemodynamic instability Splinting effect to diaphragm Increased
volume of distribution Intraoperative Respiratory distress
Hypotension if inadeq replaced after LVP Hepatic hydrothorax Risk
for SBP (50% mortality) Preoperative 89.
- Postoperative-Wound dehiscence
- Abdominal wall herniation
- 1 litre of ascitic fluid = 50ml of 25% albumin( i.e 1
litre
- roughly contains 10gm of protein).
- Albumin should be idealy used in case ofLVP(>5L/day).
- Half ofthe albumin during the procedure and the other 6 hrs
later.
Ascites Anaesthetic consideration 90. Haematological system
- Anaemia is common with chronic liver disease.
- Thrombocytopenia(qualitative as well).
- Mild thrombocytopenia is often the first manifestation of
worsening of
- fibrosis in patient with chronic hepatitis.
- Prothrombin time & partial thromboplastin time is prolonged
(mild-
- Fibrinogen level will be normal ( low fibrinogen level with
severe
- thrombocytopenia R/O DIC ).
- Drugs used to treat chronic hepatitis can cause anaemia.
- Rifampin Hemolytic anaemia
- Interferon-bone marrow suppression
91. Anaes.consideration(Haematology)
- Liver biopsy can be safely performed if
plateletcount>50,000/mm3 and PT as well
- as APTT do not exceed 1.5 times the control value( BT not a
reliable indicator).
- Avoid drugs that precipitate bleeding suchas NSAID/
Warfarin.
- Avoid IM injection to prevent haematoma.
- Haematocrit should be maintained around 30% in the
perioperative period.
- Anaemia should corrected preoperatively preferably with packed
cell or fresh
- whole blood ( Balanced against the risk of inducing HE from
haemolysed RBC).
- Thrombocytopenia in hyperspleenism as a rule is mild( severe
thrombocytopenia
- indicates the development of DIC).
92. Haematology (Cont)
- Thrombocytopenia if present should be preoperatively
corrected.
- Exploratory laprotomy>50,000/mm3
- Closed space surgery>1Lakh/mm3
- PT and APTT becomes abnormal only with severe deficiency of CF
(abnormal
- with CF < 30% of normal level).
- PT and APTT if prolonged should be corrected to be within
1.5times the control
- value.(Risk of Hge increases if PT & APTT exceeds 1.5 times
the control value).
- Failure ofPT and APTT to respond to vitK/FFP indicates
poorprognosis.
- FFP must be transfused just prior to procedure andrepeated
every 8-12hrs to
- maintain acceptable coagulation parameters( chanceof volume
overload-
- Exchange plasma transfusion).
93. Haematology(cont)
- Adequate blood/ blood component shouldbe arranged prior to
surgery.
- Invasive arterial BP preferable than NIBP(repeated NIBP
causebruises).
- Blood loss should be closely monitored &should be corrected
immedietly
- (Hematocrit maintained around 30%).
- FFP should be given when crystalloid,colloid or packed cells
aregiven to
- replace blood loss.( 1unit FFP=1unit packed cells=250ml
crystalloid)
- Hypothermia should be avoided (humidified gases,warm
ivf,warming
- blankets,forced air warming devices & blood warmer).
94. Haematology(cont)
- Blood loss can be minimised by perioperative administration of
tranexemic
- acid (prostate & ortho surgeries).
- Correct/prevent I.O. factors that increases
bleeding(dilution,hpypothermia
- hypocalcemia & acidosis).
- Thromboelastography for I.O. assesment of coagulation
parameters.
- Universal precautions in patients with hepatitis (30% - HepB
& 3% -HepC)
- Even 0.04ml blood may be enough to infect an
anaesthesiologist.
- RA not contraindicated if coagulation parameters are within
normal.
95. Causes of bleeding in liver disease
- Anatomical factors gastroesophageal varices
- Hepatic function abnormalities
- Decreased synthesis of procoagulant protein
- Decreased synthesis of coagulation inhibitors
96. Causes of bleeding in liver disease(cont)
- Failure to clear activated coagulation factors
- Impaired absorbtion and metabolism of vit k
- Synthesis of abnormal fibrinogen
- Intraoperative factors Hypothermia
97.
- 70,000-1lakh-safe if cg scn is wnl
- Activated partial thromboplastin time
Coagulation parameters and neuraxial block 98. Neuraxial
anaesthesia(cont)
- Epidural preferred than spinal anaesthesia.
- LA dose should be titrated.(flow limited drug)
- Hypotension more likely with high spinal( T4 level
- 20% decrease in HBF) but safe for lower limb
- Strict aseptic precautions increased susceptiblity
- Epidural Useful for postopanalgesia/decreases P.O
99. Indication for OLT in chronic liver disease
- A) Cholestatic condition (specific)
- Recurrent bacterial cholangitis
- progressive cholestatic bone disease
- B) Parenchymal condition (specific)
100. Indication for OLT in chronic liver disease
- C) Common to both condition
- Spontaneous bacterial peritonitis
- Severe chronic fatique & weakness.
101. V.Cholestatic jaundiceAbsentPresent Cirrhosis stigmata
Present Absent H/O of surgeryAbsent Present Prodromal symptom
Present Absent Abdominal pain Present Absent Fever Extrahepatic
Intrahepatic Diff. Features 102. Cholestatic jaundice Present
Absent Palpable gallbladder Responsive Variable Vit K treatment
Needed Not needed ERCP Present Absent B.Dilatation on USG 18
years