Intra-operative Management
🎯 Overriding intra-operative goals
- Maintain hepatic blood flow & oxygenation → keep cardiac output & MAP up, avoid hypovolaemia, hypocapnia, high PEEP/airway pressure and surgical traction on the porta. Choose organ-independent drugs, monitor coagulation and glucose, and keep the patient warm.
1
Monitoring
- Standard: SpO₂, ECG, NIBP, EtCO₂, temperature, neuromuscular (TOF), urine output.
- Invasive (major surgery): arterial line (beat-to-beat BP + ABG/glucose/lactate), central venous access; TEG/ROTEM for coagulation; cardiac-output/fluid-responsiveness monitoring for goal-directed therapy.
2
Induction & airway
- RSI with cricoid pressure if ascites, GI bleed or delayed gastric emptying (aspiration risk). Pre-oxygenate well — reduced FRC & shunt.
- Cardiostable induction (etomidate, or reduced-dose propofol); obtund the pressor response with fentanyl. Suxamethonium is acceptable for RSI; otherwise intubate with rocuronium (sugammadex available) or maintain with atracurium/cisatracurium.
3
Maintenance
- Sevoflurane or isoflurane (avoid halothane); ± remifentanil infusion; atracurium/cisatracurium for relaxation.
- Ventilate to normocapnia (hypocapnia ↓ hepatic flow); modest PEEP; lung-protective settings.
- Maintain MAP with fluids first, then noradrenaline (or vasopressin/terlipressin for splanchnic tone) — the vasodilated circulation is often catecholamine-resistant.
4
Fluids, coagulation, glucose & temperature
- Goal-directed fluid therapy — individualised, guided by fluid-responsiveness and urine output throughout; avoid both hypovolaemia and over-transfusion (raises portal pressure). Balanced crystalloid ± albumin.
- Coagulation: transfuse to the clinical picture & TEG/ROTEM — fibrinogen (cryo/concentrate), platelets, targeted FFP; consider TXA for hyperfibrinolysis. Avoid prophylactic FFP.
- Monitor and treat hypoglycaemia; correct Na⁺/K⁺; active warming (hypothermia worsens coagulopathy & drug clearance).
5
Regional anaesthesia
- Peripheral & truncal blocks reduce opioid load and are useful — but weigh neuraxial techniques against coagulopathy (epidural/spinal haematoma risk); assess platelets, fibrinogen & TEG, not just INR, and follow local thresholds.
⚠️ Potential intra-operative problems to anticipate
Coagulopathy & bleeding · hypovolaemia & hypotension (→ ↓ CO → hepatic & renal ischaemia → hypoxaemia) · hypothermia · hypoglycaemia · citrate toxicity & hypocalcaemia with massive transfusion · worsening encephalopathy · renal injury (HRS).