Pre-operative Assessment & Optimisation
History β the systems screen
Ask specifically about
Constitutional / GI: anorexia, nausea, vomiting; jaundice, fever, myalgia; upper-GI bleed (haematemesis/melaena); abdominal distension & pain; altered bowel/bladder habit.
Aetiology / exposure: alcohol intake, paracetamol/isoniazid/herbal medicine, tattoos, prior blood transfusions.
Decompensation: β urine output, leg swelling (β ascites, HRS); dayβnight reversal, confusion, tremor, altered sensorium, family-reported behavioural change (HE).
Cardiopulmonary reserve: chest pain, palpitations, syncope (cirrhotic cardiomyopathy); breathlessness lying down vs sitting up (orthodeoxia/HPS); exercise tolerance (METs <4 = poor); bleeding tendency.
Aetiology / exposure: alcohol intake, paracetamol/isoniazid/herbal medicine, tattoos, prior blood transfusions.
Decompensation: β urine output, leg swelling (β ascites, HRS); dayβnight reversal, confusion, tremor, altered sensorium, family-reported behavioural change (HE).
Cardiopulmonary reserve: chest pain, palpitations, syncope (cirrhotic cardiomyopathy); breathlessness lying down vs sitting up (orthodeoxia/HPS); exercise tolerance (METs <4 = poor); bleeding tendency.
Examination β the stigmata of chronic liver disease
π Signs to elicit (and their anaesthetic meaning)
- Pallor (anaemia) Β· icterus Β· fetor hepaticus Β· parotid enlargement Β· alopecia.
- Caput medusae / dilated abdominal veins, spider naevi (upper trunk), palmar erythema, Dupuytren's contracture.
- Gynaecomastia, testicular atrophy (sex-hormone metabolism).
- Ascites (aspiration & respiratory risk), sarcopenia / temporal wasting (frailty).
- Resting SpOβ sitting vs lying (screen for orthodeoxia/HPS); asterixis (HE).
Investigations
| Test | Why |
|---|---|
| FBC | Anaemia (nutrition/GI loss), thrombocytopenia & leucopenia (hypersplenism) |
| Coagulation β PT/INR + fibrinogen + TEG/ROTEM | Rebalanced haemostasis β assess whole-blood function, don't rely on INR alone |
| LFTs + albumin | Degree of hepatocellular vs cholestatic dysfunction; synthetic reserve |
| U&E / creatinine, electrolytes | HRS, hyponatraemia, hypokalaemia; chronic diuretic effects |
| Glucose | Hypoglycaemia risk |
| ABG / SpOβ sit-stand | HPS, hypoxaemia |
| ECG | QT prolongation, arrhythmia |
| Echocardiography (Β± bubble study, RVSP) | Cirrhotic cardiomyopathy, POPH screen, HPS shunt |
| CXR | Effusion/hydrothorax, cardiomegaly |
| USG abdomen Β± ascitic tap | Quantify ascites; exclude SBP (PMN >250) |
| Right-heart catheterisation | Confirm/quantify POPH before major surgery or transplant |
Optimisation & risk decision
1
Stratify & decide
- Calculate ChildβPugh & MELD; assess frailty. Defer elective surgery in Child C / high MELD / acute decompensation β optimise or refer for transplant.
- Weigh patient Γ surgical Γ anaesthesia factors; involve hepatology & discuss risk with the patient.
2
Correct what you can
- Ascites: salt restriction, diuretics, drain a tense abdomen (albumin cover if >5 L).
- Coagulopathy: vitamin K if cholestatic; correct fibrinogen/platelets only for active bleeding or high-risk procedures (TEG-guided) β don't chase the INR.
- Encephalopathy: treat precipitants, lactulose, rifaximin; correct electrolytes (NaβΊ, KβΊ).
- Varices: continue non-selective Ξ²-blockers; band high-risk varices before elective surgery.
- Renal/volume: avoid nephrotoxins & NSAIDs; treat SBP/HRS; optimise volume status.
3
Fasting, premed & consent
- Treat as aspiration risk if ascites / GI bleed β plan RSI. Minimise sedative premed (avoid in HE). Consider stress-ulcer & aspiration prophylaxis.