Extra Topic 1.6 -- Cirrhosis

Question 1

What would be included in your preoperative workup?

(A 51-year-old man with cirrhosis and ascites is scheduled for a right hemicolectomy secondary to colon cancer.)

Answer 1

I would –

• attempt to determine the severity of his hepatic disease by –
  
  • performing a thorough history and physical,
  • focusing on the onset and etiology of his cirrhosis, and
  • the presence of jaundice, bleeding disorder, ascites, asterixis, and hepatic encephalopathy.

Based on my findings, I may consider additional lab work to aid in discerning the severity of liver disease, including –

• bilirubin,
• transaminases,
• alkaline phosphatase,
• albumin,
• total protein,
• prothrombin time, INR, and
• hepatitis serologies.

Question 2

What are the systemic effects of cirrhosis?

(A 51-year-old man with cirrhosis and ascites is scheduled for a right hemicolectomy secondary to colon cancer.)

Answer 2

The effects of cirrhosis are multisystemic, involving –

the pulmonary, cerebral, hematologic, cardiovascular, hepatic, gastrointestinal, and renal systems.

Cirrhosis’ effects on the respiratory system include –

• intrapulmonary arteriovenous (AV) shunts,
• reduced FRC,
• restrictive lung disease,
• pleural effusions, and
• attenuation of hypoxic pulmonary vasoconstriction.

Cerebral effects include –

• the accumulation of ammonia and other toxins, which may lead to encephalopathy.

Thrombocytopenia and clotting factor deficiencies may result in coagulopathy.

Cardiovascular effects include –

• decreased peripheral vascular resistance, increased cardiac output, and cardiomyopathy.

Potential metabolic effects include –

• dilutional hyponatremia, hypokalemia, hypoglycemia, and hypoalbuminemia.

Various additional effects of cirrhosis include –

• portal hypertension, esophageal varices, delayed gastric emptying, ascites, and hepatorenal syndrome.

Question 3

How would you induce this patient?

(A 51-year-old man with cirrhosis and ascites is scheduled for a right hemicolectomy secondary to colon cancer.)

Answer 3

Given the presence of ascites (may increase the risk of aspiration via increased intra-abdominal pressure) and the potential for gastroparesis (often associated with end-stage liver disease),

I would prefer to perform a rapid sequence induction to reduce the risk of aspiration.

Therefore, assuming the patient’s airway exam was reassuring, he was hemodynamically stable, and that the appropriate monitors and intravenous access were in place, I would:

1. administer aspiration prophylaxis,
   
   • avoiding metoclopramide in the setting of bowel obstruction;
2. place the patient in the reverse trendelenburg position to reduce the risk of passive regurgitation and facilitate intubation;
3. pre-oxygenate with 100% oxygen for 5 minutes to (a.k.a. denitrogenation);
4. apply cricoid pressure;
5. administer lidocaine, propofol, and succinylcholine,
   
   • recognizing that there is the potential for prolonged neuromuscular blockade if the patient has significantly reduced pseudocholinesterase; and
6. rapidly secure the airway.

Question 4

What muscle relaxant would you use for maintenance?

(A 51-year-old man with cirrhosis and ascites is scheduled for a right hemicolectomy secondary to colon cancer.)

Answer 4

I would prefer to use a muscle relaxant that is not dependent on hepatic metabolism, such as Cis-Atracurium.

This drug’s duration of action should not be affected by liver failure, because it undergoes degradation in the plasma by Hofmann elimination, and is reduced to inactive metabolites.

However, if I felt it was clinically indicated, I could use a muscle relaxant that is dependent on hepatic metabolism.

If this were the case, I would recognize the potential for prolonged duration of action, carefully titrate the muscle relaxant, and monitor neuromuscular function with a nerve stimulator.

Question 5

A liter of ascitic fluid was lost following opening of the abdomen, and the patient becomes hypotensive.

What is your differential diagnosis?

(A 51-year-old man with cirrhosis and ascites is scheduled for a right hemicolectomy secondary to colon cancer.)

Answer 5

The timing of the hypotension suggests that a significant loss of ascitic fluid leading to large fluid shifts may have been the cause of his hypotension.

However, my differential would also include –

• surgical or gastrointestinal bleeding,
• tension pneumothorax,
• hypoxia,
• cardiac arrhythmia, or
• cardiac failure.

What would you do?

If the hypotension were significant, I would –

• auscultate the chest,
• ensure adequate ventilation and oxygenation,
• check the EKG,
• examine the surgical field for blood loss,
• recheck the blood pressure, and
• administer a fluid bolus, vasopressors, and inotropes as indicated.