1. Principles of anesthesia in cirrhotic patients
Jean Mantz, MD, PhD
Professor of Anesthesia and Critical Care
Chairman, Department of Anesthesia and Critical Care, Beaujon University Hospital
INSERM U 676
University of Paris

2. Anesthesia and cirrhosis
Principles of perioperative management
Anesthesia and cirrhosis in:
Liver transplantation
Liver resection
Endoscopic procedures
Conclusion

3. Cirrhotic patients: Risk factors for perioperative morbi-mortality Ziser et al Anesthesiology 1999; 90: 42-53
Risk factors
Morbidity (%)
30 day mortality (%)
6 month mortality (%)
Child-Pugh score C vs AB     42 15 31
Ascite 48 20 39
Renal failure 21 36
COPD 41 18 29
Preoperative sepsis 74 49 60
GI bleeding 70 12 23
ASA status 4 or 5 68 32 52
Major surgery (thoracic, voies biliary, abodminal, septic)
Intraoperative hypotension 45 26
Cause other than PBC 33 14 24

4. Cirrhotic patients: Risk factors for perioperative morbi-mortality Ziser et al Anesthesiology 1999; 90: 42-53
Risk factors
Morbidity (%)
30 day mortality (%)
6 month mortality (%)
Child-Pugh score C vs AB     42 15 31
Ascite 48 20 39
Renal failure 21 36
COPD 41 18 29
Preoperative sepsis 74 49 60
GI bleeding 70 12 23
ASA status 4 or 5 68 32 52
Major surgery (thoracic, voies biliary, abodminal, septic)
Intraoperative hypotension 45 26
Cause other than PBC 33 14 24

6. Cirrhotic patients: Risk factors for perioperative morbi-mortality Ziser et al Anesthesiology 1999; 90: 42-53
Risk factors
Morbidity (%)
30 day mortality (%)
6 month mortality (%)
Child-Pugh score C vs AB     42 15 31
Ascite 48 20 39
Renal failure 21 36
COPD 41 18 29
Preoperative sepsis 74 49 60
GI bleeding 70 12 23
ASA status 4 or 5 68 32 52
Major surgery (thoracic, voies biliary, abodminal, septic)
Intraoperative hypotension 45 26
Cause other than PBC 33 14 24

7. Venous compliance in cirrhosis Hadengue et al, Hepatology 1992
300 mL gélatine en 3 min

8. Fluid management
Hypovolemia
Fluid overload

10. Preoperative risk evaluation
Circulatory (hyperkinetic profile with low SVR, high venous compliance, coronaropathy or cardiomoypathy, pulmonary hypertension)
Ventilatory (Hypoxemia, intrapulmonary shunt, restrictive syndrome (ascite, pleural effusion)

12. Preoperative risk evaluation
Circulatory (hyperkinetic profile with low SVR, high venous compliance, coronaropathy or cardiomoypathy, pulmonary hypertension)
Ventilatory (Hypoxemia, intrapulmonary shunt, restrictive syndrome (ascite, pleural effusion)
Renal (hypovolemia, hepatorenal syndrome)
Cerebral (encephalopathy, cerebral edema)
Coagulation (hypo-/ hypercoagulability, fibrinolysis)
Pharmacokinetic/dynamic changes to drug effects

13. Choice of anesthetic agents/techniques
Risks of regional anesthesia
Use intravenous anesthetics with elimination independent from cytochrome P450 activity (Propofol AIVOC, ketamine, etomidate, fentanyl, sufentanil, remifentanil, atracurium/cisatracurium)
Volatile anesthetics: desflurane/sevoflurane
Maintain hemodynamic stability +++
MONITOR and TITRATE+++

14. Patient
Risk/benefit balance
of anesthesia and surgery
Anesthesiologist
Surgeon
Hepatologist/
Gastroenterologist

15. Intraoperative period
Short acting anesthetics
Postoperative analgesia
Prevention of PONV
Reversal of muscle relaxants
Maintenance of normovolemia, hemoglobin levels
Prevention of awareness
Maintenance of normothermia
Maintain oxygenation
Restrictive fluid therapy
Avoid hyperglycemia
Start postoperative rehabilitation

16. Intraoperative period
Short acting anesthetics
Postoperative analgesia
Prevention of PONV
Reversal of muscle relaxants
Maintenance of normovolemia, hemoglobin levels
Prevention of awareness
Maintenance of normothermia
Maintain oxygenation
Restrictive fluid therapy
Avoid hyperglycemia
Start postoperative rehabilitation

17. Cirrhosis and coagulation abnormalities
Antihemostatic
Prohemostatic
Thrombocytopenia
Alteration of platelet functions
 FvW and FVIII
 Factors II, V, VII, IX, X, XI
Abnormalities of fibrinogen
 Protein C, protein S, protein Z, AT(III), heparin-CoFII, 2-macroglobulin
 2-anti-plasmine, TAFI
 t-PA
 plasminogen
 PAI-1
T. Lisman et al. J Hepatol 2002;37:280-7

18. Hepatology 2006,44:53-61

19. Coagulation abnormalities
Cirrhosis
Coagulation abnormalities
Hemorrhage

20. Coagulation abnormalities
Cirrhosis
Coagulation abnormalities
Portal hypertension ?
Hemorrhage

21. Postoperative rehabilitation
Multimodal analgesia
Early extubation
Early removal of tubes and catheters
Early mobilization
Thromboprophylaxis
Early enteral nutrition
Hydratation

22. Postoperative rehabilitation
Multimodal analgesia
Early extubation
Early removal of tubes and catheters
Early mobilization
Thromboprophylaxis
Early enteral nutrition
Hydratation

23. Liver transplantation in Beaujon: recipients

24. (n=215)
(n=212)
(n=242)
(n=77)
(n=51)

25. Survival / indications
Cirrhosis (n=416)
Others (n=72)
HCC (n=248)
Fulminans (n=139)

28. Anesthesia for endoscopic procedures.
High risk anesthesia +++
Outside the OR
Inhalation of gastric content
Obstructive hypoxemia
Hemorrhage and perforation
Pulmonary hypertension

30. Indications for endotracheal intubation
Esophageal varices treatment (inhalation risk+++)
Radiofrequency (painful procedures)
Other indications:
Long duration procedure (> 1h))
Comorbidities (obesity, major ascite, diabetic dysautonomia)

33. Conclusion
Cirrhotic patients are at high risk of postoperative morbi-mortality
Discuss the risk/benefit balance of surgery and anesthesia
Maintain hemodynamic stability (monitor, titrate)
There is no « minor » anesthesia

34. Thank you for your kind attention