Effects of Desflurane versus sevoflurane on graft outcome of patients with cirrhosis receiving steatotic liver graft in deceased donor liver transplantation

STUDY OBJECTIVE

This study aimed to analyze the effects of two volatile anesthetic agents, desflurane and sevoflurane, on graft outcomes in patients undergoing deceased donor liver transplantation (DDLT) for cirrhosis, with a specific focus on fatty grafts.

DESIGN

A retrospective observational study.

SETTING

A tertiary hospital (Severance Hospital, Korea).

PATIENTS

This study included 151 patients with liver cirrhosis who underwent DDLT for cirrhosis between January 2006 and December 2022.

INTERVENTIONS

Patients were grouped according to maintenance anesthesia received (desflurane or sevoflurane), the model for end-stage liver disease (MELD) score, and macrovesicular steatosis (MVS) of the liver graft.

MEASUREMENTS

Survival curves were constructed from the date of surgery to graft failure or death. After propensity score matching (PSM), Cox regression analysis was used to compare hazards ratios (HR) for 5-year graft and overall survival. Subgroup analyses were performed for the MELD score and MVS of the liver graft. Incidences of 1-month acute rejection and early allograft dysfunction (EAD) were also compared between the two groups.

MAIN RESULTS

Among 151 eligible patients, 49 patients remained in each group after PSM, with 14 (28.6 %) graft failures and deaths occurring in each group. In matched analysis, sevoflurane showed poorer 5-year graft and overall survival compared to desflurane in recipients of graft with ≥10 % MVS, and this trend was significant in patients with MELD score of ≥35. In Cox regression model, compared to desflurane sevoflurane showed a propensity score-matched HR of 5.8 (95 % CI, 1.13-30.50 for both 5-year graft and overall survival. Additionally, sevoflurane showed an increased risk of 1-month acute rejection; however, no difference was observed for EAD.

CONCLUSIONS

Sevoflurane as a maintenance agent during DDLT in recipients with high MELD scores and fatty grafts may be associated with poorer outcomes compared to desflurane.

High daily caffeine intake is associated with lower propofol requirements for anesthetic induction

Background and Aims

There is significant interindividual variation in the dose of propofol required for anesthetic induction. Factors dictating this are poorly described, but understanding them would be useful for anesthetic drug dosing. It has been shown in rats and recently in humans that caffeine administration accelerates recovery from anesthesia, but no study has assessed the effect on anesthetic induction.

Material and Methods

Forty American Society of Anesthesiologists (ASA)-I, 18-65-year-old patients, undergoing day case general anesthesia with propofol and fentanyl took part in this observational study. Total daily caffeine intake (mg) was estimated using the caffeine assessment tool and caffeine content values from the US Department of Agriculture National Nutrient Database. Pharmacokinetic-pharmacodynamic modeling was used to estimate the effect site concentration of propofol at loss of consciousness (Ce(p) LOC).

Results

Median (interquartile range [IQR]) daily caffeine intake was 106 (51-193) mg. Ce(p) LOC was lower in those with caffeine intake greater than or equal to the median of 106 mg (median (IQR) = 0.64 μg/ml (0.51-0.72) vs. 0.70 μg/ml (0.57-1.10), P = 0.04). The effect was robust when controlling for weight-adjusted fentanyl dose, age, smoking status, and alcohol intake (F (1,34) = 4.66, P = 0.04).

Conclusion

High daily caffeine intake is associated with lower propofol requirements for day case anesthetic induction. We propose that high daily caffeine intake may cause lower arousal levels prior to surgery due to a relative caffeine deficit caused by being nil by mouth. As such, assessment of daily caffeine intake preoperatively may aid anesthetic drug dosing.

The Management of Postoperative Cognitive Dysfunction in Cirrhotic Patients: An Overview of the Literature

Background and objectives: Postoperative cognitive dysfunction (POCD) represents a decreased cognitive performance in patients undergoing general anesthesia for major surgery. Since liver cirrhosis is associated with high mortality and morbidity rates, cirrhotic patients also assemble many risk factors for POCD. Therefore, preserving cognition after major surgery is a priority, especially in this group of patients. The purpose of this review is to summarize the current knowledge regarding the effectiveness of perioperative therapeutic strategies in terms of cognitive dysfunction reduction. Data Collection: Using medical search engines such as PubMed, Google Scholar, and Cochrane library, we analyzed articles on topics such as: POCD, perioperative management in patients with cirrhosis, hepatic encephalopathy, general anesthesia in patients with liver cirrhosis, depth of anesthesia, virtual reality in perioperative settings. We included 115 relevant original articles, reviews and meta-analyses, and other article types such as case reports, guidelines, editorials, and medical books. Results: According to the reviewed literature, the predictive capacity of the common clinical tools used to quantify cognitive dysfunction in cirrhotic settings is reduced in perioperative settings; however, novel neuropsychological tools could manage to better identify the subclinical forms of perioperative cognitive impairments in cirrhotic patients. Moreover, patients with preoperative hepatic encephalopathy could benefit from specific preventive strategies aimed to reduce the risk of further neurocognitive deterioration. Intraoperatively, the adequate monitoring of the anesthesia depth, appropriate anesthetics use, and an opioid-sparing technique have shown favorable results in terms of POCD. Early recovery after surgery (ERAS) protocols should be implemented in the postoperative setting. Other pharmacological strategies provided conflicting results in reducing POCD in cirrhotic patients. Conclusions: The perioperative management of the cognitive function of cirrhotic patients is challenging for anesthesia providers, with specific and targeted therapies for POCD still sparse. Therefore, the implementation of preventive strategies appears to remain the optimal attitude. Further research is needed for a better understanding of POCD, especially in cirrhotic patients.

Liver Fibrosis Marker and Postoperative Mortality in Patients Without Overt Liver Disease

BACKGROUND

Nonalcoholic fatty liver disease (NAFLD) can progress to advanced fibrosis, which, in the nonsurgical population, is associated with poor hepatic and extrahepatic outcomes. Despite its high prevalence, NAFLD and related liver fibrosis may be overlooked during the preoperative evaluation, and the role of liver fibrosis as an independent risk factor for surgical-related mortality has yet to be tested. The aim of this study was to assess whether fibrosis-4 (FIB-4), which consists of age, aspartate aminotransferase (AST), alanine aminotransferase (ALT), and platelets, a validated marker of liver fibrosis, is associated with postoperative mortality in the general surgical population.

METHODS

A historical cohort of patients undergoing general anesthesia at an academic medical center between 2014 and 2018 was analyzed. Exclusion criteria included known liver disease, acute liver disease or hepatic failure, and alcohol use disorder. FIB-4 score was categorized into 3 validated predefined categories: FIB-4 ≤1.3, ruling out advanced fibrosis; >1.3 and <2.67, inconclusive; and ≥2.67, suggesting advanced fibrosis. The primary analytic method was propensity score matching (FIB-4 was dichotomized to indicate advanced fibrosis), and a secondary analysis included a multivariable logistic regression.

RESULTS

Of 19,861 included subjects, 1995 (10%) had advanced fibrosis per FIB-4 criteria. Mortality occurred intraoperatively in 15 patients (0.1%), during hospitalization in 272 patients (1.4%), and within 30 days of surgery in 417 patients (2.1%). FIB-4 ≥2.67 was associated with increased intraoperative mortality (odds ratio [OR], 3.63; 95% confidence interval [CI], 1.25-10.58), mortality during hospitalization (OR, 3.14; 95% CI, 2.37-4.16), and within 30 days from surgery (OR, 2.46; 95% CI, 1.95-3.10), after adjusting for other risk factors. FIB-4 was related to increased mortality in a dose-dependent manner for the 3 FIB-4 categories ≤1.3 (reference), >1.3 and <2.67, and ≥2.67, respectively; during hospitalization (OR, 1.89; 95% CI, 1.34-2.65 and OR, 4.70; 95% CI, 3.27-6.76) and within 30 days from surgery (OR, 1.77; 95% CI, 1.36-2.31 and OR, 3.55; 95% CI, 2.65-4.77). In a 1:1 propensity-matched sample (N = 1994 per group), the differences in mortality remained. Comparing the FIB-4 ≥2.67 versus the FIB-4 <2.67 groups, respectively, mortality during hospitalization was 5.1% vs 2.2% (OR, 2.70; 95% CI, 1.81-4.02), and 30-day mortality was 6.6% vs 3.4% (OR, 2.26; 95% CI, 1.62-3.14).

CONCLUSIONS

A simple liver fibrosis marker is strongly associated with perioperative mortality in a population without apparent liver disease, and may aid in future surgical risk stratification and preoperative optimization.

Evaluating the incidence of spinal cord injury after spinal cord stimulator implant: an updated retrospective review

INTRODUCTION

While spinal cord stimulator implant is an increasingly safe procedure, one of the most feared complications is spinal cord injury. Still, literature regarding its incidence remains highly variable. This retrospective analysis aims to evaluate the incidence of spinal cord injury after spinal cord stimulator implant using a large-scale claims database.

METHODS

The PearlDiver-Mariner database of national all payer claims was used to identify patients who underwent spinal cord stimulator implant (percutaneous or paddle) and developed subsequent spinal cord injury within 45 days. The primary outcome was to determine the overall incidence of spinal cord injury after spinal cord stimulator implant. Secondary outcomes included an evaluation of potential factors associated with developing spinal cord injury using univariable and multivariable regression analysis.

RESULTS

A total of 71,172 patients who underwent a spinal cord stimulator implant were included in the analysis, of which 52,070 underwent percutaneous and 19,102 underwent paddle spinal cord stimulator lead implant. The overall incidence of spinal cord injury after spinal cord stimulator implant (any lead type) was found to be 0.42% (302 patients). The incidence of spinal cord injury after percutaneous and paddle lead implants did not differ at 0.45% (233 patients) and 0.36% (69 patients)(p=0.12), respectively. Overall, variables associated with a significantly increased OR (95% confidence interval) of developing spinal cord injury included male gender by 1.31 times (1.04 to 1.65)(p=0.02); having a claim for low molecular weight heparin within 30 days by 3.99 times (1.47 to 10.82)(p<0.01); a diagnosis for osteoporosis within 1 year by 1.75 times (1.15 to 2.66)(p<0.01); and a diagnosis of cervical or thoracic spinal canal stenosis within 1 year by 1.99 (1.37 to 2.90)(p<0.001) and 4.00 (2.63 to 6.09)(p<0.0001) times, respectively.

CONCLUSIONS

Overall, our results support the notion that spinal cord stimulator implant continues to be a safe procedure for chronic pain patients. However, risk factor mitigation strategies for the prevention of spinal cord injury after spinal cord stimulator implant should be undertaken prior to performing the procedure.

Pre-procedural Preparation and Sedation for Gastrointestinal Endoscopy in Patients with Advanced Liver Disease

Gastrointestinal endoscopy in patients with advanced liver disease poses various challenges, a major one being procedural sedation and its associated considerations. While sedation during endoscopy can improve patient comfort, decrease anxiety, and facilitate procedural completion, in patients with advanced liver disease, it is also associated with substantial and unique risks due to alterations in drug metabolism and other factors. As such, the choice of sedative agent(s) and related logistics may require careful inter-disciplinary planning and individualized considerations. Furthermore, a large proportion of agents require dose reductions and particular monitoring of the vital signs, level of consciousness, and other indices. In the present review, we provide a contemporary overview of procedural sedation considerations, commonly used intravenous sedatives, and second-line as well as novel sedatives for gastrointestinal endoscopy in patients with advanced liver disease.

Perioperative management of patients with liver disease for non-hepatic surgery: A systematic review

Background

Liver disease is a multisystem condition that is classified as acute or chronic depending on the length of time. Cirrhosis patients are expected to undergo surgery in the last two years of their lives, according to estimates. In patients with elevated liver enzyme levels, anesthesia and surgery may deteriorate liver function. Preoperative identification, optimization and anesthetic management are essential for optimum outcomes in patients with liver disease undergoing surgery.

Methods

The literatures are searched using medical search engines like Google scholar, PubMed, Cochrane library and HINARI to get access for current and update evidence on perioperative optimization of patients with liver disease. The key words for literature search were (liver disease OR liver failure) AND (liver disease OR perioperative management) AND (non-hepatic surgery OR anesthesia). After searching using these search engines then collected by filtering based on the level of significance to this guideline with proper appraisal and evaluation of study quality with different level of evidences.

Conclusions

and recommendations: Patients with liver disease presenting with non-hepatic surgery might have postoperative complications that can lead to death. Efforts should be expended to favorably alter a patient's preoperative Child's class before undertaking an elective operation.

•

Liver disease is a multisystem condition that is classified as acute or chronic.

•

Preoperative assessment and risk stratification are paramount for optimization.

•

Nephrotoxic drugs should be avoided.

The effects of cardiovascular and orthopaedic surgery on vitamin concentrations: a narrative review of the literature and mechanisms of action

Given the rise in worldwide chronic diseases, supplemented by an aging population, the volume of global major surgeries, encompassing cardiac and orthopedic procedures is anticipated to surge significantly. Surgical trauma can be accompanied by numerous postoperative complications and metabolic changes. The present review summarized the results from studies assessing the effects of orthopedic and cardiovascular surgery on vitamin concentrations, in addition to exploring the possible mechanisms associated with changes in concentrations. Studies have revealed a potentially severe depletion in plasma/serum concentrations of numerous vitamins following these surgeries acutely. Vitamins C, D and B1 appear particularly vulnerable to significant depletions, with vitamin C and D depletions consistently transpiring into inadequate and deficient concentrations, respectively. The possible multifactorial mechanisms impacting postoperative vitamin concentrations include changes in hemodilution and vitamin utilization, redistribution, circulatory transport and absorption. For a majority of vitamins, there has been a lack of investigation into the effects of both, cardiac and orthopedic surgery. Additionally, studies were predominantly restricted to short-term postoperative investigations, primarily performed within the first postoperative week of surgery. Overall, results indicated that further examination is necessary to determine the severity and clinical significance of the possible depletions in vitamin concentrations that ensue cardiovascular and orthopedic surgery.

Muscle-Invasive Bladder Cancer in Patients with Liver Cirrhosis: A Review of Pertinent Considerations

The incidence of liver cirrhosis is increasing worldwide. Patients with cirrhosis are generally at a higher risk of harbouring hepatic and non-hepatic malignancies, including bladder cancer, likely due to the presence of related risk factors such as smoking. Cirrhosis can complicate both the operative and non-surgical management of bladder cancer. For example, cirrhotic patients undergoing abdominal surgery generally demonstrate worse postoperative outcomes, and chemotherapy in patients with cirrhosis often requires dose reduction due to its direct hepatotoxic effects and reduced hepatic clearance. Multiple other considerations in the peri-operative management for cirrhosis patients with muscle-invasive bladder cancer must be taken into account to optimize outcomes in these patients. Unfortunately, the current literature specifically related to the treatment of cirrhotic bladder cancer patients remains sparse. We aim to review the literature on treatment considerations for this patient population with respect to perioperative, surgical, and adjuvant management.

Pharmacokinetic properties of remimazolam in subjects with hepatic or renal impairment

BACKGROUND

Remimazolam is a new benzodiazepine for procedural sedation and general anaesthesia. The aim of this study was to characterise its pharmacokinetic properties and safety in renally and hepatically impaired subjects.

METHODS

Two separate trials were conducted in patients with hepatic (n=11) or renal impairment (n=11) compared with matched healthy subjects (n=9 and n=12, respectively). The hepatic impairment trial was an open-label adaptive 'Reduced Design' trial, using a single bolus of remimazolam 0.1 mg kg^-1 i.v., whereas the renal impairment trial was an open-label trial of a single bolus dose of remimazolam 1.5 mg i.v. Remimazolam plasma concentrations over time were analysed by population pharmacokinetic modelling.

RESULTS

Remimazolam pharmacokinetic properties were adequately described by a three-compartment, recirculatory model. Exposure in subjects with severe hepatic impairment was 38.1% higher (i.e. clearance was 38.1% lower) compared with healthy volunteers. This increase caused a slightly delayed recovery (8.0 min for healthy, 12.1 min for moderate, and 16.7 min for severe hepatic impairment). With renal impairment, plasma clearance was comparable with that measured in healthy subjects. Simulations of C_max after a bolus dose of 10 mg showed no relevant impact of hepatic or renal impairment. The overall incidence of adverse events was low, and all adverse events were mild.

CONCLUSIONS

As C_max after a remimazolam bolus i.v. was not affected by hepatic or renal impairment, no dose adjustments are required. No unexpected adverse events related to remimazolam were seen in subjects with renal or hepatic impairment.

CLINICAL TRIAL REGISTRATION

Hepatic impairment trial: ClinicalTrials.gov, NCT01790607 (https://clinicaltrials.gov/ct2/show/NCT01790607). Renal impairment trial: EudraCT Number: 2014-004575-23.

Budd-Chiari syndrome diagnosed with pregnancy in a patient with inherited thrombophilia

An 18-year-old primigravida was referred to our high risk pregnancy (HRP) department at 34 weeks of gestation for birth panning as she has Budd-Chiari syndrome (BCS). Her history was significant for familial thrombophilia. She had portal hypertension manifestations. Her work-up revealed factor V Leiden gene mutation, hepatic and portal vein thrombosis. A multidisciplinary team of physicians from the gastroenterology and hepatology, haematology and HRP departments puts a management plan; it culminated into safe delivery of the patient at 36 weeks of gestation. The patient was referred to a specialised BCS centre where she had successful liver transplantation done.

Drugs and the liver

The liver is a major organ with multiple functions. A number of drugs are metabolized by the liver during phase 1 and 2 reactions which include complex processes involving cytochrome P450 enzymes. Genetic and acquired variability in cytochrome P450 activity may have profound effects on pharmacokinetics. Additionally, drugs can also modify how the liver functions and cause dysfunction or even failure of the organ both by a direct effect on the liver or by alteration in liver blood flow. It is important to recognize the signs and symptoms of liver failure in patients and identify possible causes including drug interactions. Furthermore, once a patient has been recognized to be suffering with liver dysfunction or failure drug choice and dosing regime will need to be rationalized.

Paracetamol overdose can have severe and life threatening consequences for patients due to its effect on liver function. It is the leading cause of acute liver failure in the UK,¹ Correct and early management is crucial and will be discussed within this article.

Preoperative Evaluation and Anesthetic Management of Patients With Liver Cirrhosis Undergoing Cardiac Surgery

Preoperative evaluation and anesthetic management of patients with liver cirrhosis undergoing cardiac surgery remain a clinical challenge because of its high risk for perioperative complications. This narrative review article summarizes the pathophysiology and anesthetic implication of liver cirrhosis on each organ system. It will help physicians to evaluate surgical candidates, to optimize intraoperative management, and to anticipate complications in liver cirrhosis patients undergoing cardiac surgery. Morbidity typically results from bleeding, sepsis, multisystem organ failure, or hepatic insufficiency. These complications occur as a result of the presence of coagulopathy, poor nutritional status, immune dysfunction, cirrhotic cardiomyopathy, and renal and pulmonary dysfunction that occur with liver cirrhosis. Therefore, liver cirrhosis should not be seen as a single disease, but one that manifests with multiorgan dysfunction. Cardiac surgery in patients with liver cirrhosis increases the risk of perioperative complications, and it presents a particular challenge to the anesthesiologist in that nearly every aspect of normally functioning physiology may be jeopardized in a unique way. Accurately classifying the extent of liver disease, preoperative optimization, and surgical risk communication with the patient are crucial. In addition, all teams involved in the surgery should communicate openly and coordinate in order to ensure optimal care. To reduce perioperative complications, consider using off-pump cardiopulmonary bypass techniques and optimal perfusion modalities to mimic current physiologic conditions.

Comparative effect of desflurane and sevoflurane on liver function tests of patients with impaired hepatic function undergoing cholecystectomy: A randomized clinical study

Background and Aim:

Desflurane and sevoflurane are the most common volatile anesthetics used during laparoscopic and hepatic surgery. The objective of the study was to evaluate the effect of desflurane and sevoflurane in patients with elevated preoperative liver functions undergoing laparoscopic cholecystectomy.

Methods:

The study was a randomized study and included 162 patients classified randomly into two groups: Desflurane group: The patients received desflurane (end-tidal concentration 4%–6%) as an inhalational agent during the whole procedure. Sevoflurane group: The patients received sevoflurane (end-tidal concentration 2%–4%) as an inhalational agent during the whole procedure. The investigations included serum level of aspartate aminotransferase (AST), alanine aminotransferase (ALT), alkaline phosphatase (ALP), gamma-glutamyltransferase (GGT), and total bilirubin. The values were serially collected at the following timepoints; T0:at the preoperative period, T1:directly after surgery, T2:1^st postoperative day, T3:2^nd postoperative day, T4:3^rd postoperative day, T5:5^th postoperative day, T6:7^th postoperative day, and T7:10^th postoperative day. The statistics were described in terms of mean ± standard deviation, frequencies, and percentages.

Results:

The preoperative liver enzymes and total bilirubin were higher than the normal range in patients of the two groups. Postoperatively, there was a decrease in the AST and ALT with desflurane more than sevoflurane from T1 to T6(P < 0.05). The ALP, GGT, and bilirubin decreased in patients of the two groups, but the comparison was insignificant (P > 0.05).

Conclusion:

The desflurane is a safe inhalational volatile for maintenance of anesthesia in patients with impaired liver function undergoing laparoscopic cholecystectomy. It was associated with a decrease in the liver enzymes more than the sevoflurane.

A randomized controlled trial evaluating general endotracheal anesthesia versus monitored anesthesia care and the incidence of sedation-related adverse events during ERCP in high-risk patients

BACKGROUND AND AIMS

ERCP is a complex procedure often performed in patients at high risk for sedation-related adverse events (SRAEs). However, there is no current standard of care with regard to mode of sedation and airway management during ERCP. The aim of this study was to assess the safety of general endotracheal anesthesia (GEA) versus propofol-based monitored anesthesia care (MAC) without endotracheal intubation in patients undergoing ERCP at high risk for SRAEs.

METHODS

Consecutive patients undergoing ERCP at high risk for SRAEs at a single center were invited to participate in this randomized controlled trial comparing GEA and MAC. Inclusion criteria were STOP-BANG score ≥3, abdominal ascites, body mass index ≥35, chronic lung disease, American Society of Anesthesiologists class >3, Mallampati class 4 airway, and moderate to heavy alcohol use. Exclusion criteria were preceding EUS, emergent ERCP, tracheostomy, unstable airway, gastric outlet obstruction or delayed gastric emptying, and altered foregut anatomy. The primary endpoint was composite incidence of SRAEs: hypoxemia, use of airway maneuvers, hypotension requiring vasopressors, sedation-related procedure interruption, cardiac arrhythmia, and respiratory failure. Secondary outcomes included procedure duration, cannulation success, in-room time, and immediate adverse events.

RESULTS

Two hundred patients (mean age, 61.1 ± 13.6 years; 36.5% women) were randomly assigned to GEA (n = 101) or MAC (n = 99) groups. Composite SRAEs were significantly higher in the MAC group compared with the GEA group (51.5% vs 9.9%, P < .001). This was primarily driven by the frequent need for airway maneuvers in the MAC group. Additionally, ERCP was interrupted in 10.1% of patients in the MAC group to convert to GEA because of respiratory instability refractory to airway maneuvers (n = 8) or significant retained gastric contents (n = 2). There were no statistically significant differences in cannulation, in-room, procedure, or fluoroscopy times between the 2 groups. All patients undergoing GEA were successfully extubated in the procedure room at completion of ERCP, and Aldrete scores in recovery did not differ between the 2 groups. There were no immediate adverse events.

CONCLUSION

In patients at high risk for SRAEs undergoing ERCP, sedation with GEA is associated with a significantly lower incidence of SRAEs, without impacting procedure duration, success, recovery, or in-room time. These data suggest that GEA should be used for ERCP in patients at high risk for SRAEs (Clinical trial registration number: NCT02850887.).

Transjugular biopsy case report of inferior vena cava hepatocellular carcinoma with intracardiac extension

BACKGROUND

Diagnosis of hepatocellular carcinoma (HCC) can be established with near certainty by correlating radiological imaging with clinical presentation. However, in the absence of diagnostic certainty, biopsy of liver tissue is mandatory for optimal management. We present our management of a patient with advanced liver disease who presented with an IVC mass extending into the right atrium, with co-existing liver lesions not meeting criteria for an imaging diagnosis of HCC.

CASE PRESENTATION

A 62-year-old male with Child-Pugh C liver cirrhosis presented with decompensated liver failure. Multiple imaging modalities demonstrated an inferior vena cava (IVC) mass extending into the right atrium with co-existing liver lesions not meeting radiological criteria for an imaging diagnosis of HCC. There was no contiguous evidence of HCC in the liver, yet there was extensive tumour burden in the IVC representing a separate metastatic lesion without any indication of direct tumour spread. Under fluoroscopic and angiographic guidance, a biopsy catheter was advanced through the right atrium into the IVC. Histology from the biopsy demonstrated fragments of malignant tumour with features consistent with moderately differentiated HCC without thrombus. Given the poor prognosis associated with metastatic HCC with IVC and intracardiac involvement, a multidisciplinary decision was made with the patient's family for palliation care.

CONCLUSION

Transjugular biopsy of IVC masses can be performed effectively, in an awake patient, without the need for sedation or anaesthesia. Where multiple imaging modalities fail to confirm a diagnosis for liver or IVC pathology, transluminal biopsy can assist with definitive diagnosis and treatment planning.

Perioperative Care of Patients With Liver Cirrhosis: A Review

The incidence of cirrhosis is rising, and identification of these patients prior to undergoing any surgical procedure is crucial. The preoperative risk stratification using validated scores, such as Child-Turcotte-Pugh (CTP) and Model for End-Stage Liver Disease, perioperative optimization of hemodynamics and metabolic derangements, and postoperative monitoring to minimize the risk of hepatic decompensation and complications are essential components of medical management. The advanced stage of cirrhosis, emergency surgery, open surgeries, old age, and coexistence of medical comorbidities are main factors influencing the clinical outcome of these patients. Perioperative management of patients with cirrhosis warrants special attention to nutritional status, fluid and electrolyte balance, control of ascites, excluding preexisting infections, correction of coagulopathy and thrombocytopenia, and avoidance of nephrotoxic and hepatotoxic medications. Transjugular intrahepatic portosystemic shunt may improve the CTP class, and semielective surgeries may be feasible. Emergency surgery, whenever possible, should be avoided.

Anesthesia Patients with Concomitant Cardiac and Hepatic Dysfunction

Anesthesia and surgery in patients with hepatic and cardiac dysfunction poses a challenge for anesthesiologists. It is imperative to optimize these patients perioperatively. Cirrhosis is associated with a wide range of cardiovascular abnormalities. Cirrhotic cardiomyopathy is characterized by blunted contractile responsiveness or systolic incompetence, and/or diastolic dysfunction. In liver disease, anesthetic drug distribution, metabolism, and elimination may be altered. Among patients with liver disease, propofol is a reasonable anesthetic choice and cisatracurium is the preferred neuromuscular blocker. Regional anesthesia should be used whenever appropriate if not contraindicated by coagulopathy, because it reduces the need for systemic analgesia.

Intravenous hypnotic regimens in patients with liver disease; a review article

CONTEXT

The liver as an important organ in the body has many essential functions in physiological processes. One of the major activities of liver is drug metabolism. Hepatic dysfunction affecting hepatic physiological activities, especially drug metabolism can cause many problems during anesthesia and administration of different drugs to patients.

EVIDENCE ACQUISITION

Studies on hepatic disorders and hypnotic anesthetics prescribed in hepatic disorders were included in this review. For this purpose, reliable databases were used.

RESULTS

Anesthesia should be performed with caution in patients with hepatic dysfunction and drugs with long half-life should be avoided in these patients.

CONCLUSIONS

A review of the literature on the use of hypnotic drugs in patients with liver dysfunction showed that some hypnotic drugs used during anesthesia could be safely used in patients with impaired liver function. In these patients, certain drugs should be used with caution.

The role of inhalational anesthetic drugs in patients with hepatic dysfunction: a review article

Context:

Anesthetic drugs including halogenated anesthetics have been common for many years. Consequent hepatic injury has been reported in the literature. The mechanism of injury is immunoallergic. The first generation drug was halothane; it had the most toxicity when compared to other drugs. The issue becomes more important when the patient has an underlying hepatic dysfunction.

Evidence Acquisition:

In this paper, reputable internet databases from 1957–2014 were analyzed and 43 original articles, 3 case reports, and 3 books were studied. A search was performed based on the following keywords: inhalational anesthesia, hepatic dysfunction, halogenated anesthetics, general anesthesia in patients with hepatic diseases, and side effects of halogenated anesthetics from reliable databases. Reputable websites like PubMed and Cochrane were used for the searches.

Results:

In patients with hepatic dysfunction in addition to hepatic system and dramatic hemostatic dysfunction, dysfunction of cardiovascular, renal, respiratory, gastrointestinal, and central nervous systems may occur. On the other hand, exposure to inhalational halogenated anesthetics may have a negative impact (similar to hepatitis) on all aforementioned systems in addition to direct effects on liver function as well as the effects are more pronounced in halothane.

Conclusions:

Despite the adverse effects of inhalational halogenated anesthetics (especially halothane) on hepatic patients when necessary. The effects on all systems must be considered and the necessary preparations must be provided. These drugs are still used, if necessary, due to the presence of positive effects and advantages mentioned in other studies as well as the adverse effects of other drugs.

Remifentanil, fentanyl, or the combination in surgical procedures in the United States: predictors of use in patients with organ impairment or obesity

INTRODUCTION

Remifentanil has a rapid onset and short duration of action, predictable pharmacokinetic/pharmacodynamic profile, and unlike fentanyl, does not accumulate with repeated or prolonged administration. This study evaluated predictors of remifentanil use in surgical patients with renal or hepatic impairment, or obesity in the United States who received remifentanil, fentanyl, or the combination.

METHODS

Data (2010) from the US Healthcare National Inpatient Database, State Inpatient Database, State Ambulatory Surgery Database, and private hospital and Medicaid databases were used in this analysis. Patients included had presence of hepatic or renal disease, and/or obesity and were >5 and ≤80 years of age.

RESULTS

In 2010, 9,274 patients with renal impairment, 1,896 with hepatic impairment, and 6,278 with obesity were identified. The percentage of surgical patients diagnosed with renal disease, hepatic disease, or obesity who received remifentanil was 41, 28, and 35%, respectively; 29, 17, and 22% received both remifentanil and fentanyl, and 30, 55, and 43% received fentanyl alone, respectively. In patients with renal or hepatic disease the probability of remifentanil use was greater for persons aged >50 years, with Medicare as primary payer, or who were diagnosed with obesity (p < 0.05 all comparisons). In obese patients, the probability of remifentanil use was greater for persons aged >50 years or female (both p < 0.05). For all 3 disease states, the probability of remifentanil use was lower for those receiving epidural anesthesia or with Medicaid as primary payer (p < 0.05 all comparisons).

CONCLUSION

Remifentanil in combination with fentanyl is used less than fentanyl in surgical patients with hepatic impairment or obesity. This is inconsistent with the fact that the pharmacokinetic/pharmacodynamic features of remifentanil suggest it is the preferred intraoperative opioid in these patients. Predictors of remifentanil use in patients with renal or hepatic impairment, or obesity include older age, obesity, and Medicare as primary payer. Remifentanil in combination with fentanyl was significantly less utilized than fentanyl in persons with Medicaid as primary payer even though there was a disproportionate enrollment of beneficiaries with renal or hepatic disease, or obesity in state Medicaid programs.

Copper and anesthesia: clinical relevance and management of copper related disorders

Recent research has implicated abnormal copper homeostasis in the underlying pathophysiology of several clinically important disorders, some of which may be encountered by the anesthetist in daily clinical practice. The purpose of this narrative review is to summarize the physiology and pharmacology of copper, the clinical implications of abnormal copper metabolism, and the subsequent influence of altered copper homeostasis on anesthetic management.