Common Mistakes in Anaesthesia for CLD
Cirrhotic coagulopathy is rebalanced; INR does not predict bleeding. Prophylactic FFP raises portal pressure and can worsen variceal bleeding. Use TEG/ROTEM and treat fibrinogen/platelets for actual bleeding.
Morphine (M-6-G) and pethidine (norpethidine) accumulate; benzodiazepines precipitate encephalopathy. Titrate, prefer fentanyl/remifentanil, and minimise premed.
Vecuronium, rocuronium and pancuronium are prolonged. Use atracurium/cisatracurium (Hofmann) and monitor TOF; have sugammadex for roc/vec.
Ascites and GI bleeding raise intra-abdominal pressure and delay emptying. Plan an RSI; don't do a gentle gas induction on a tense, bleeding abdomen.
The portal vein can't autoregulate and the HABR is impaired under anaesthesia — hypotension, low CO and hypocapnia cause hepatic ischaemia. Maintain MAP, normocapnia and flow.
Halothane risks immune hepatitis; NSAIDs and aminoglycosides precipitate HRS. Choose sevoflurane/isoflurane and protect the kidney.
Mortality is prohibitive. Optimise, involve hepatology, and defer or refer for transplant where possible.
Hypoglycaemia (depleted glycogen) and hypothermia (worsens coagulopathy & drug clearance) are silent and preventable.
Exam Pearls
Q: Describe the dual blood supply and the HABR.
Hepatic artery 20–30% (high O₂), portal vein 70–80% (low O₂) — each supplies ~half the O₂. The hepatic arterial buffer response keeps total flow constant via adenosine washout: ↓ portal flow → adenosine accumulates → HA dilates. The portal vein cannot autoregulate, and the HABR is blunted by anaesthesia/hypotension.
Q: Why doesn't INR predict bleeding in cirrhosis?
Both pro- and anti-coagulant factors fall together (rebalanced haemostasis); factor VIII & vWF are made outside the liver and may be normal/high. Assess with TEG/ROTEM, fibrinogen and platelets, not INR alone.
Q: Muscle relaxant & opioid of choice?
Relaxant — atracurium/cisatracurium (Hofmann elimination, organ-independent). Opioid — remifentanil (plasma esterase) if infusing; fentanyl for boluses. Avoid morphine (M-6-G) and pethidine (norpethidine).
Q: Compare CTP and MELD.
CTP = albumin, bilirubin, INR, ascites, encephalopathy (A-B-E-A-I) → 1-month mortality; subjective, excludes renal function. MELD = creatinine, bilirubin, INR (objective, includes kidney) → 3-month mortality; MELD-Na → 1-year. Child A operative mortality ~10%, B ~30%, C ~70%+.
Q: Define the hepatopulmonary syndrome.
Triad: liver disease + intrapulmonary vascular dilatation + hypoxaemia (A–a gradient ≥15). Hallmark orthodeoxia (SpO₂ falls on standing). Dx: contrast echo / Tc-99m MAA scan. Rx: O₂; definitive = transplant.
Q: How does POPH differ, and when is transplant contraindicated?
POPH = pulmonary arterial hypertension from portal HTN (mPAP >25, PCWP <15, PVR >3 WU). mPAP >50 with high PVR contraindicates transplant. Rx: prostacyclin, bosentan, sildenafil, inhaled NO.
Q: Pathogenesis & treatment of hepatic encephalopathy?
Gut-derived ammonia bypasses the liver → astrocyte glutamine ↑ → swelling → altered neurotransmission. West Haven I–IV. Treat precipitants (GI bleed, sepsis, electrolytes, sedatives), lactulose, rifaximin.
Q: What is hepatorenal syndrome and how is it treated?
Functional, pre-renal renal failure from splanchnic vasodilatation → renal vasoconstriction; diagnosis of exclusion (no shock, nephrotoxins or structural disease; no response to albumin + diuretic withdrawal). Rx: albumin + terlipressin (or midodrine/octreotide/noradrenaline); definitive = transplant.
Q: SAAG interpretation?
SAAG ≥1.1 g/dL = portal hypertension (cirrhosis, alcoholic hepatitis, cardiac); <1.1 = non-portal (TB, malignancy, nephrotic, pancreatic).
Q: Which volatile agents, and why avoid halothane?
Isoflurane best preserves hepatic blood flow; sevoflurane is minimally metabolised and preferred. Halothane (≈20% metabolised) → oxidative/reductive metabolites & immune "halothane hepatitis" — avoid.
References
- Hines RL, Marschall KE (eds). Stoelting's Anesthesia and Co-Existing Disease, 8th Edition. Liver Diseases. Elsevier; 2022.
- Gropper MA, et al. (eds). Miller's Anesthesia, 9th Edition. Anesthesia for Hepatic Surgery & Patients with Liver Disease. Elsevier; 2020.
- Barash PG, et al. (eds). Clinical Anesthesia, 9th Edition. Anesthesia and the Hepatobiliary System. Wolters Kluwer; 2023.
- Butterworth JF, Mackey DC, Wasnick JD. Morgan & Mikhail's Clinical Anesthesiology, 6th Edition. Anesthesia for Patients with Liver Disease. McGraw-Hill; 2018.
- Stoelting RK, Hillier SC. Pharmacology & Physiology in Anesthetic Practice, 6th Edition. Hepatic Drug Clearance & the Extraction Ratio. Wolters Kluwer; 2021.
- European Association for the Study of the Liver (EASL). Clinical Practice Guidelines on the management of ascites, SBP, and hepatorenal syndrome; and on decompensated cirrhosis. J Hepatol.
- Northup PG, et al. Coagulation in liver disease — rebalanced haemostasis. Hepatology / J Hepatol.
- Compiled from the teaching notes of Dr. Tanya Chawla (Anaesthesia & Critical Care).