Risk Stratification in a Patient of Liver Disease

7/31/2019 Risk Stratification in a Patient of Liver Disease

1/27

Presented by:Dr.Sachin Anand

Mod By: Dr.Sanjiv Aneja


2/27

INTRODUCTIONPatients with end-stage liver disease often undergo surgery for

indications other than liver transplantation. These patients havean increased risk of morbidity and mortality that is related totheir underlying liver disease.

Assessments of surgical risk provide a basis for discussion of risks

and benefits, treatment decision making, and for optimalmanagement of patients for whom surgery is planned. The mostuseful indicators of surgical risk are indices that predict advanceddisease, such as the

ChildTurcottePugh score, or those that predict prognosis, such asthe Model for End-stage Liver Disease score.

Careful preoperative risk assessment, patient selection, andmanagement of various manifestations of advanced disease mightdecrease morbidity and mortality from nontransplant surgery inpatients with liver disease.


3/27

Patients with liver disease who require surgeryare at greater risk for surgical and anesthesia

related complications than those with ahealthy liver . The magnitude of the riskdepends upon

the type of liver disease and its severity, the surgical procedure, and

the type of anesthesia.


4/27

SCREENING FOR LIVER DISEASE BEFORE

SURGERYPatients undergoing surgery should undergo a history and

physical examination to exclude findings or risk factorsfor liver disease. This may include asking about

prior blood transfusions,

tattoos, illicit drug use, sexual promiscuity,

a family history of jaundice or liver disease,

a history of jaundice or fever following anesthesia,

alcohol use (current, prior and quantity), and

a complete review of current medications.


5/27

EXAMINATION

Clinical features suggestive of liver disease ,such as fatigue,

pruritus,

increased abdominal girth,

jaundice,

palmar erythema,

spider telangiectasias,

splenomegaly, and gynecomastia and testicular atrophy in men should be

evaluated.


6/27

EFFECTS OF ANESTHESIA AND SURGERY ON

THE LIVER

The effects of anesthesia and surgery on the liver dependupon

the type of anesthesia used,

the specific surgical procedures, and

the severity of liver disease. In addition,

perioperative events, such as

hypotension,

sepsis, or the administration of hepatotoxic drugs,

can compound injury to the liver occurring during theprocedure


7/27

EFFECT OF LIVER DISEASE ON SURGERY

AND ANESTHESIAThe presence of liver disease can increase the risks of surgery

and anesthesia in several ways

Hepatic dysfunction can significantly impair themetabolism of certain medications used peri-operatively.

A hyperdynamic circulation, with elevated cardiac outputand decreased systemic vascular resistance.

The compensatory inotropic and chronotropic response ofthe heart to pharmacologic and physiologic stressors,including surgery, is blunted.

Induction of anesthesia,hemorrhage, hypoxemiahypotension, use of vasoactive medicationsand even thepatients position and the surgical technique usedcan alldecrease intraoperative and perioperative oxygen delivery to

the liver and increase the risk of hepatic dysfunction


8/27

ESTIMATING THE RISK OF SURGERYPostoperative outcomes are markedly influenced by the

severity and nature of the underlying liver disease and the

type of surgery being consideredNature of the underlying liver disease

Obstructive jaundice risk factors include

an initial hematocrit less than 30%,

a serum total bilirubin concentration above 11 mg/dl,

the presence of malignancy,

a serum creatinine concentration higher than 1.4 mg/dl,

serum albumin concentration less than 3.0 g/dl, age older than 65 years,

aspartate aminotransferase concentration above 90 IU/l,and

blood urea nitrogen concentration above 10 mg/dl


9/27

Acute hepatitis

Patients with acute hepatitis have increased morbidity

and mortality associated with surgery. These increases probably occur as a result of the acute

hepatocellular injury and associated hepaticdysfunction.

As most cases of acute hepatitis are self-limited and

symptoms ultimately resolve, elective surgery should bepostponed until the patients clinical, bio chemical and

histologic parameters return to baseline. overall morbidity and mortality are increased in

patients with acute alcoholic hepatitis, and electivesurgery is contraindicated in these patients


10/27

Chronic hepatitis

The etiology of chronic hepatitis does not seem to

influence a patients perioperative risk Surgery is considered safe in asymptomatic patients

with histologic evidence of mildly active hepatitis,

symptomatic patients with histologic evidence of

severely active hepatitis have been shown to be atincreased risk from surgery

increased morbidity and mortality in patients withmoderate to severe steatosis (>30%) who underwentmajor hepatic resection,with mean BMI greater than30 kg/m2, and pre operative bilirubin levels elevated(mean 2.2 mg/dl), which indicated significantunderlying hepatic dysfunction


11/27

Cirrhosis

In patients with cirrhosis, perioperative risk can be

influenced by hepatic dysfunction,

Portal hypertension

complications such as intraabdominal varices, ascites,

renal dysfunction, and

portopulmonary hypertension


12/27

Severity of the underlying liver disease

An accurate assessment of the extent and severity of the patients underlying liverdisease is required for an effective determination of their perioperative risk.

The ChildTurcottePugh (CTP) score

the Model for End-stage Liver Disease (MELD) score have both been used forthis purpose.

ChildTurcottePugh score The CTP score was the first-described predictorof surgical riskthis score was

originally designed by Child and Turcotte to predict mortality after portocavalshunt surgery,

later modified by Pugh et al. to include prothrombin time in place of nutritionalstatus for use in patients undergoing esophageal transections of bleeding varices.

Although the CTP score has not been prospectively validated, it has stood thetest of time, and has been widely used to assess disease severity in patients withcirrhosis and to predict their risks of perioperative morbidity and mortality forboth elective and emergency surgery.


13/27


14/27

In cirrhotic patients who undergo abdominal surgery,

CTP classes A, B and C are associated with mortality of10%, 3031% and 7682%, respectively.

The subjective nature of the clinical parameters and thearbitrary cut-off points used for the biochemical

parameters limit the accuracy of the CTP score as apredictor of surgical risk.

An example of the limitations of the CTP score isshown by the fact that patients with CTP class A

cirrhosis can still have ascites, hyperbilirubinemia andportal hypertension.


15/27

Model for End-Stage Liver Disease

The MELD score was originally devised as a prognosticmeasure of short-term mortality in patients with cirrhosis

who were undergoing placement of a transjugularintrahepatic portosystemic shunt.

The MELD assigns the patient a score of 840, which isderived from a complex formula that incorporates threebiochemical variablesthe serum total bilirubinconcentration, serum creatinine concentration, andinternational normalized ratio.

The MELD score has been prospectively validated as a

prognostic marker of mortality in patients with cirrhosis,acute variceal bleeding or acute alcoholic hepatitis.

A modified MELD score was adopted by the UnitedNetwork for Organ Sharing in February 2002 for the

purposes of donor liver allocation


16/27

Model for End-stage Liver Disease score.

MELD score = (9.6 loge[creatinine mg/dl]) + (3.8

loge[bilirubin mg/dl]) + (11.2 loge[INR]) + 6.4 The final score is rounded off to the nearest whole

number and the maximum score is 40 (scores largerthan 40 are assigned a value of 40). For any laboratory

values less than 1.0 a value of 1.0 is used.

The maximum creatinine concentration is 4.0 mg/dl(creatinine concentrations higher than 4.0 mg/dl areassigned a value of 4.0 mg/dl). If a patient has haddialysis twice within the previous week, the creatininevalue is set as 4.0 mg/dl.

.


17/27

Other approachesAlternative approaches used to determine the severity of

hepatic disease include

liver scintigraphy(using 99mTc-galactosyl-labeledhuman serum albumin),

the indocyanine-green retention test,

the aminopyrine breath test, and measurement of the lidocaine metabolite

monoethylglycinexylidide.

Mainly test hepatic reserve


18/27

Type of surgeryEmergency surgery

emergency abdominal surgery or surgery as a result oftrauma,

Patient outcomes worsen with increasing CTP scores.

Abdominal surgery

Abdominal surgical proceduressuch as gastric bypass,biliary procedures, ulcer surgery and colonic resections.

Cholecystectomy, although the risk seems to be highest forthose who undergo non laparoscopic and emergencycholecystectomy.

pre operative placement of transjugular intrahepaticportosystemic shunts in patients with cirrhosis and portalhypertension, to improve portal hypertension and allowsurgery to be successfully completed.


19/27

Cardiac surgery

In patients with cirrhosis ,cardiopulmonary bypass hasan increased perioperative risk.

study of 18 patients who underwent cardiac surgerywith cardiopulmonary bypass demonstrated mortality

rates of 0%, 50%, and 100% for patients with CTPclasses A, B, and C, cirrhosis, respectively.

The increased morbidity and mortality were caused byan elevated incidence of bleeding and sepsis.

Another study revealed patients with a CTP score of 8or higher had significantly higher postoperativemortality than those with a CTP score below 8.


20/27

Hepatic resectionSurgical resection of localized hepatocellular carcinoma in patients

with cirrhosis raises. concerns about the adequacy of residual

hepatic. These patients Have increased rates of perioperative complications,

long-term hepatic decompensation, and

death following resection,

thus patient selection is critical.

The absence of portal hypertension measured by hepatic veincatheterization (a hepatic vein pressure gradient 10 mmHg) and anelevated total bilirubin concentration of (>1 mg/dl) are associated

with 5-year survival rates below 30%, regardless of the patients

CTP classification.


21/27

RECOMMENDATIONS FOR PREOPERATIVE

EVALUATION

General recommendations in the preoperative evaluation of patients withliver disease. CTP class A cirrhosis- Elective surgery can proceed CTP class B cirrhosis, hepatic resection and cardiac surgery should be

avoided, and the patients condition should be optimized before electivesurgery.

CTP class C cirrhosis, elective surgery is contraindicated and nonsurgical options should be pursued.A patient with a MELD score Below 10 can undergo elective surgery, Caution needs to be exercised for a patient with a MELD score of 1015. MELD score above 15, elective surgery should be avoided and the

patients candidacy for liver transplantation should be considered. In particular, the risk of adverse outcomes from orthopedic or urologic

procedures is lower than from abdominal or cardiac surgery. Portal hypertension is a superior predictor of poor outcome in patients

with cirrhosis who are undergoing hepatic resection, compared CTPscore.


22/27

SummaryHigh-risk patients with liver disease for any type of

surgery

Childs C

MELD score greater than 15

Acute liver failure

Acute alcoholic hepatitis

High serum bilirubin (>11 mg/dL)

Portal hypertension with an elevated hepatic veinpressure gradient (>10 mmHg)


23/27

SummaryHigh-risk surgery in patients with liver disease

Abdominal surgery

Cholecystectomy Colectomy

Gastric surgery

Liver resection

Cardiac surgery

Emergent surgery (any type)

Surgery with high anticipated blood loss


24/27

PREOPERATIVE MANAGEMENT


25/27

PREOPERATIVE MANAGEMENT

Clinical manifestation- Management considerationsNutritional status

Maintenance of an adequate protein intake (11.5 g/kg per day).

Promotion of a balanced diet

Coagulopathy

Vitamin K supplementation (oral or parenteral) ,

Fresh, frozen plasma transfusions

Intravenous administration of cryoprecipitate

Intravenous administration of recombinant factor VIIa

Platelet transfusions

Ascites

Paracentesis with analysis of ascitic f luid for evidence of infection

Dietary sodium restriction (


26/27

Renal dysfunction Avoidance of nephrotoxic insult Albumin infusion (with paracentesis volumes >5 l)

Portosystemic encephalopathy Correction of reversible metabolic factors Avoidance of sedatives and opioid narcotics, as far as possible Oral lactulose administration, titrated to ~34 bowel movements per

day

Administration of nonabsorbable antibiotics Decreased protein intakePulmonary hepatic vascular disorders Supportive care Supplemental oxygen


27/27

Thank You

Date post:	05-Apr-2018
Category:	Documents
Upload:	drsachinuc
View:	220 times
Download:	0 times

Risk Stratification in a Patient of Liver Disease

Documents