Anesthesia for the Patient with Severe Liver Failure

Role of Opioid-Sparing Techniques in Pain Management for General Surgery Patients With Hepatic Dysfunction: An Observational Cohort Study

Introduction Patients with hepatic dysfunction undergoing general surgery face significant perioperative risks due to the liver's critical role in drug metabolism and systemic homeostasis. Opioid-sparing techniques may mitigate these risks by reducing opioid consumption and minimizing hepatic complications. Objective The objective of the study was to evaluate the effectiveness of opioid-sparing techniques in pain management for general surgery patients with hepatic dysfunction and their impact on postoperative outcomes. Methodology This observational cohort study was conducted at Lady Reading Hospital, Peshawar, Pakistan, from November 2023 to October 2024. A total of 100 patients with hepatic dysfunction undergoing elective general surgeries were included, with 50 managed using opioid-sparing techniques and 50 receiving opioid-based analgesia. Pain was assessed using the Numeric Rating Scale (NRS) at six, 12, 24, and 48 hours post-surgery. Opioid consumption was quantified as morphine-equivalent doses over 48 hours. Hepatic function parameters (aspartate aminotransferase (AST), alanine aminotransferase (ALT), and total bilirubin) and postoperative outcomes, including complications and hospital stay, were analyzed. Results Postoperative pain scores were significantly lower in the opioid-sparing group across all time points (e.g., NRS at six hours: 2.9 ± 0.8 vs. 4.5 ± 1.1, p < 0.001). Opioid consumption was reduced by 67% in the opioid-sparing group (4.1 ± 1.5 mg vs. 12.6 ± 3.8 mg,p < 0.001). Hepatic function parameters remained stable in both groups. The opioid-sparing group had shorter hospital stays (3.8 ± 0.9 days vs. 5.1 ± 1.2 days, p < 0.001) and fewer complications, including nausea (12% vs. 30%, p = 0.02) and respiratory depression (0% vs. 10%, p = 0.04). Conclusion Opioid-sparing techniques improve pain management, reduce opioid consumption, and minimize postoperative complications in patients with hepatic dysfunction undergoing general surgery. These findings support incorporating opioid-sparing protocols into perioperative care for this high-risk population.

Surgical Considerations in Portal Hypertension

This review provides an in-depth exploration of portal hypertension (PH) and its implications in various surgical procedures. The prevalence of clinically significant PH is 50% to 60% in compensated cirrhosis and 100% in decompensated cirrhosis. The feasibility and safety of hepatic and nonhepatic surgical procedures in patients with PH has been shown. Adequate preoperative risk assessment and optimization of PH are integral parts of patient assessment. The occurrence of adverse outcomes after surgery has decreased over time in this specific population, due to the development of techniques and improved perioperative multidisciplinary care.

Position paper on perioperative management and surgical risk in the patient with cirrhosis

INTRODUCTION

Management of the patient with cirrhosis of the liver that requires surgical treatment has been relatively unexplored. In Mexico, there is currently no formal stance or expert recommendations to guide clinical decision-making in this context.

AIMS

The present position paper reviews the existing evidence on risks, prognoses, precautions, special care, and specific management or procedures for patients with cirrhosis that require surgical interventions or invasive procedures. Our aim is to provide recommendations by an expert panel, based on the best published evidence, and consequently ensure timely, quality, efficient, and low-risk care for this specific group of patients.

RESULTS

Twenty-seven recommendations were developed that address preoperative considerations, intraoperative settings, and postoperative follow-up and care.

CONCLUSIONS

The assessment and care of patients with cirrhosis that require major surgical or invasive procedures should be overseen by a multidisciplinary team that includes the anesthesiologist, hepatologist, gastroenterologist, and clinical nutritionist. With respect to decompensated patients, a nephrology specialist may be required, given that kidney function is also a parameter involved in the prognosis of these patients.

General anesthesia in patients with hepatic encephalopathy and acute variceal bleeding undergoing endoscopic treatment: A retrospective study

The management of cirrhotic patient with encephalopathy and acute variceal bleeding (AVB) remains a clinical challenge with a high mortality. Early endoscopic therapies are frequently applied in patients with AVB. However, the application of general anesthesia in endoscopic surgery for patients with hepatic encephalopathy (HE) is pretty challenging. The present study aimed to evaluate the possible effect of general anesthesia with tracheal intubation on patient complicated with encephalopathy and AVB during endoscopic procedure. Thirty-six cirrhotic patients with encephalopathy and AVB were retrospectively studied, 14 patients underwent endoscopic treatment under general anesthesia with tracheal intubation, and 22 patients received pharmacological treatment, or and endoscopic therapy without general anesthesia served as the control group. Routine clinical and laboratory data were collected. The total mortality rate was 13.9% (5/36), 2 (14.3%) in the anesthesia group, 3 (13.6%) in the control group. The child-Pugh class of death cases were all grade C, 3 (60%) of them were in the stage IV of HE. The stage of HE was all improved in the 2 groups, 12 (85.8 %) patients were totally recovered from consciousness disturbance in the anesthesia group and 16 (72.7 %) in the control group respectively, the difference between the 2 groups was not significant (P>0.05). Except the death cases, there were still 3 patients in the control group had impaired consciousness at discharge. Child-Pugh score, Child-Pugh class and the stage of HE in the anesthesia group were significantly improved at discharge compared with those before operation. General anesthesia does not aggravate the severity of encephalopathy, and endoscopic treatment under general anesthesia with tracheal intubation is effective for HE patients complicated with AVB.

Individualized Management of Coagulopathy in Patients with End-Stage Liver Disease

Over the last decades, individualized approaches and a better understanding of coagulopathy complexity in end-stage liver disease (ESLD) patients has evolved. The risk of both thrombosis and bleeding during minimally invasive interventions or surgery is associated with a worse outcome in this patient population. Despite deranged quantitative and qualitative coagulation laboratory parameters, prophylactic coagulation management is unnecessary for patients who do not bleed. Transfusion of red blood cells (RBCs) and blood products carries independent risks for morbidity and mortality, including modulation of the immune system with increased risk for nosocomial infections. Optimal coagulation management in these complex patients should be based on the analysis of standard coagulation tests (SCTs) and viscoelastic tests (VETs). VETs represent an individualized approach to patients and can provide information about coagulation dynamics in a concise period of time. This narrative review will deliver the pathophysiology of deranged hemostasis in ESLD, explore the difficulties of evaluating the coagulopathies in liver disease patients, and examine the use of VET assays and management of coagulopathy using coagulation factors. Methods: A selective literature search with PubMed as the central database was performed with the following.