"Cirrhosis is a multisystem disease that disturbs the pharmacology of almost every anaesthetic drug and the physiology of every organ system. This topic is split into short, focused tabs — read them in order, or jump straight to what you need. The same tabs sit at the top of every page."
How to use this topic — CritCare.in.Why Chronic Liver Disease Matters to the Anaesthetist
"Cirrhosis is a multisystem disease. The liver is central to drug metabolism, protein synthesis, coagulation and glucose homeostasis, so hepatic failure disturbs the pharmacology of almost every anaesthetic drug and the physiology of every organ system. Perioperative mortality tracks the severity of liver dysfunction (Child–Pugh, MELD) far more than the magnitude of surgery — and elective surgery in decompensated cirrhosis should be deferred until the patient is optimised or transplanted."
Synthesised from Stoelting's Anesthesia and Co-Existing Disease, 8th Ed & Miller's Anesthesia, 9th Ed.- Altered pharmacokinetics — large volume of distribution, low albumin (↑ free drug), and slow clearance → unpredictable, prolonged drug effect.
- Hyperdynamic circulation with a fixed, exhausted reserve — ↑CO, ↓SVR, blunted baroreflex and cirrhotic cardiomyopathy — they tolerate hypovolaemia and vasodilatation poorly.
- Rebalanced but fragile haemostasis — both pro- and anti-coagulant factors are low; a normal-looking INR is not reassuring and does not predict bleeding.
- Portal hypertension — varices (torrential bleeding), ascites (aspiration risk, restrictive respiration), and portosystemic shunting of ammonia and drugs.
- Vulnerable end organs — the kidney (hepatorenal syndrome), lungs (hepatopulmonary syndrome / portopulmonary hypertension), and brain (encephalopathy) decompensate with any perioperative insult.
This page is built around Dr. Tanya Chawla's notes and triangulated with the standard anaesthesia texts. It works through the anatomy & physiology first, then the pathophysiology by system, the scoring systems, the altered drug handling, and finally a practical pre-op → intra-op → post-op plan. Where useful, think of the assessment along three axes: patient factors (severity of liver disease and its multisystem effects), surgical factors (site, urgency, blood loss, open vs laparoscopic), and anaesthesia factors (drug choice, monitoring, regional vs general).
Liver Anatomy & Physiology
Functions of the liver, the dual blood supply, the hepatic arterial buffer response, regulation of hepatic blood flow and how to read LFTs.
🧩02 · PATHOPHYSIOLOGYCirrhosis, Portal HTN & Systemic Effects
Causes by site, HVPG and decompensation; the hyperdynamic circulation, cirrhotic cardiomyopathy, HPS/POPH, encephalopathy, HRS and rebalanced coagulopathy.
💧03 · COMPLICATIONSAscites, Varices & SBP
Ascites pathogenesis, SAAG & grades, diuretics and large-volume paracentesis; porto-systemic shunts and the acute variceal-bleed algorithm; SBP.
📊04 · SCORINGChild–Pugh, MELD & Frailty
CTP with class-wise mortality, MELD/MELD-Na, which score predicts which mortality, and the Liver Frailty Index.
💊05 · PHARMACOLOGYAltered Drug Handling
The three PK changes, the extraction ratio, phase I vs II, and an agent-by-agent table — the drugs of choice in liver disease.
📋06 · PRE-OPPre-operative Assessment
History & stigmata, investigations, and optimisation of ascites, coagulopathy, encephalopathy, varices and renal/volume status.
🗺️07 · INTRA-OPIntra-operative Management
Monitoring, RSI, maintaining hepatic blood flow, goal-directed fluids, coagulation, glucose, temperature and regional anaesthesia.
🛏️08 · POST-OPPost-operative Care & Analgesia
Watching for decompensation, HRS, bleeding & sepsis; the opioid-sparing analgesia ladder; the Indian context.
🎓09 · PEARLSMistakes, Pearls & References
Common mistakes, viva-ready exam pearls and the reference list.