Post-operative Care & Analgesia
🔎 What to watch for
- Hepatic decompensation & encephalopathy — minimise sedatives/opioids, continue lactulose, correct electrolytes, avoid constipation, look for a GI bleed.
- Renal function (HRS) — hourly urine output, avoid nephrotoxins & hypovolaemia, maintain MAP & albumin.
- Bleeding & delayed drug effects — residual neuromuscular block (confirm reversal), prolonged sedation.
- Sepsis / SBP, hypoglycaemia, hypothermia, respiratory failure.
- High-risk patients → HDU/ICU. The pre-operative MELD is a good guide to post-operative mortality risk.
Analgesia ladder in liver disease
① Regional first: epidural infusion of dilute bupivacaine (opioid-sparing) or a peripheral / truncal nerve block — provided coagulation is acceptable.
② Paracetamol — safe at a reduced dose (≤2–3 g/day) and short duration; still the multimodal backbone.
③ Opioids — use sparingly and titrated; prefer fentanyl; expect prolonged effect; avoid morphine/pethidine accumulation.
④ Avoid NSAIDs — GI-bleed & renal (HRS) risk, and platelet effect.
② Paracetamol — safe at a reduced dose (≤2–3 g/day) and short duration; still the multimodal backbone.
③ Opioids — use sparingly and titrated; prefer fentanyl; expect prolonged effect; avoid morphine/pethidine accumulation.
④ Avoid NSAIDs — GI-bleed & renal (HRS) risk, and platelet effect.
🇮🇳 Indian Context
The dominant aetiologies are hepatitis B/C and alcohol-related liver disease, often presenting late and decompensated. Practical realities: terlipressin is widely available and first-line for variceal bleeding & HRS; viscoelastic testing (TEG/ROTEM) and human albumin may be limited outside tertiary centres — so use component therapy judiciously, avoid over-transfusing FFP, and don't correct INR reflexively. Take strict universal blood/body-fluid precautions (high hepatitis B/C prevalence). Where a liver-transplant programme is not accessible, honest risk communication and deferral of non-essential elective surgery in Child C / high-MELD patients is essential.