# Anesthesia for the Patient with Liver Disease

## Introduction

The liver is central to drug metabolism, coagulation factor synthesis, glucose homeostasis, and immune function. Patients with liver disease present unique perioperative challenges ranging from altered pharmacokinetics to catastrophic hemorrhage. Understanding the spectrum of hepatic dysfunction, from compensated cirrhosis to acute liver failure, is essential for safe anesthetic management.

## Classification and Severity of Liver Disease

### Child-Turcotte-Pugh (CTP) Score

| Parameter | 1 point | 2 points | 3 points |
|-----------|---------|----------|----------|
| Bilirubin (mg/dL) | <2 | 2-3 | >3 |
| Albumin (g/dL) | >3.5 | 2.8-3.5 | <2.8 |
| INR | <1.7 | 1.7-2.3 | >2.3 |
| Ascites | None | Mild | Moderate-severe |
| Encephalopathy | None | Grade I-II | Grade III-IV |

Class A (5 to 6 points) indicates well-compensated disease with perioperative mortality of approximately 10%. Class B (7 to 9 points) indicates significant compromise with perioperative mortality of approximately 30%. Class C (10 to 15 points) indicates decompensated disease with perioperative mortality exceeding 75% for abdominal surgery.

### MELD Score

The Model for End-Stage Liver Disease uses bilirubin, creatinine, and INR. A MELD greater than 15 is associated with significantly increased perioperative mortality. A MELD greater than 20 should prompt consideration of whether elective surgery should be deferred until after transplantation.

## Pathophysiology Relevant to Anesthesia

### Cardiovascular

Cirrhotic patients have a hyperdynamic circulation with high cardiac output, low SVR, and reduced MAP (cirrhotic cardiomyopathy). Portopulmonary hypertension, which is pulmonary artery hypertension in the setting of portal hypertension, presents a relative contraindication to surgery when the mean pulmonary artery pressure exceeds 35 mmHg. Hepatopulmonary syndrome involves intrapulmonary vascular dilatation causing hypoxemia and is diagnosed by contrast echocardiography.

### Pulmonary

Restrictive physiology results from ascites and pleural effusions. Decreased FRC, atelectasis, and ventilation-perfusion mismatch are common. Hepatopulmonary syndrome may cause severe hypoxemia refractory to supplemental oxygen.

### Hematologic

Coagulopathy results from decreased synthesis of factors II, V, VII, IX, and X, as well as decreased protein C, protein S, and antithrombin III. However, the concept of rebalanced hemostasis is important: both procoagulant and anticoagulant pathways are impaired, and INR does not reliably predict bleeding risk. Thrombocytopenia results from splenic sequestration and decreased thrombopoietin production. Hyperfibrinolysis may contribute to diffuse microvascular bleeding.

### Hepatorenal Considerations

Hepatorenal syndrome is a functional renal failure resulting from splanchnic vasodilation and renal vasoconstriction. Dilutional hyponatremia is common and correlates with disease severity. Nephrotoxic agents must be avoided, and renal perfusion pressure must be maintained.

### Pharmacokinetic Alterations

Decreased hepatic blood flow reduces first-pass metabolism. Reduced albumin leads to an increased free fraction of protein-bound drugs. Phase I metabolism (oxidation, reduction) is more affected than Phase II (conjugation). Increased volume of distribution for hydrophilic drugs occurs due to ascites and edema.

![Diagram showing the systemic effects of cirrhosis organized by organ system with arrows indicating pathophysiologic relationships](images/cirrhosis-systemic-effects.png)

## Preoperative Assessment

The history should address the etiology of liver disease, prior decompensation (variceal bleeding, ascites, encephalopathy, hepatorenal syndrome), alcohol use, and viral hepatitis status. Laboratory studies include CBC, CMP (including albumin, bilirubin, transaminases), coagulation studies (PT/INR, fibrinogen), and MELD score calculation. Imaging should assess for ascites, portal hypertension (splenomegaly, varices), and hepatocellular carcinoma. Cardiac evaluation with echocardiography assesses for cirrhotic cardiomyopathy and portopulmonary hypertension. Risk stratification uses CTP class and MELD score, with consideration of hepatology consultation.

## Anesthetic Management

### General Principles

Elective surgery should be avoided in decompensated cirrhosis (CTP C), with optimization and stabilization pursued first. Drugs metabolized by ester hydrolysis or organ-independent elimination should be chosen when possible. Hepatic blood flow must be maintained by avoiding hypotension, excessive PEEP, and high intra-abdominal pressure. Preparation for significant hemorrhage requires large-bore IV access, an arterial line, and type and screen or crossmatch.

### Drug Selection

For induction, propofol is used at reduced doses due to hypoalbuminemia and low SVR. Etomidate is hemodynamically stable but should be limited to single-dose use. For maintenance, volatile agents are acceptable; all reduce hepatic blood flow in a dose-dependent fashion, with isoflurane and sevoflurane preferred (desflurane is also acceptable). Among neuromuscular blockers, cisatracurium is preferred due to its Hofmann elimination and organ-independent metabolism. Rocuronium has a prolonged duration but can be reversed with sugammadex. For opioids, remifentanil is ideal (ester hydrolysis), and fentanyl is acceptable. Morphine should be avoided (active metabolites, prolonged duration), and all opioid doses should be reduced. Benzodiazepines have prolonged duration and should be used cautiously; midazolam has reduced clearance. Succinylcholine may have prolonged action due to decreased pseudocholinesterase but is still usable for RSI.

### Coagulation Management

Viscoelastic testing (TEG/ROTEM) is superior to conventional coagulation tests for guiding transfusion in cirrhotic patients. The goal is to transfuse to maintain hemostasis, not to normalize the INR. FFP should be used judiciously because large volumes may worsen portal hypertension. Cryoprecipitate is given if fibrinogen is less than 150 to 200 mg/dL, and platelets if the count is less than 50,000 per microliter with active bleeding. Tranexamic acid or aminocaproic acid is indicated for hyperfibrinolysis.

### Hemodynamic Management

An arterial line provides continuous blood pressure monitoring and enables frequent laboratory sampling. Central venous access allows vasopressor infusion and volume administration. Vasopressin may be particularly effective given the relative vasopressin deficiency in cirrhosis. Norepinephrine is first-line for persistent hypotension. Excessive fluid administration should be avoided as it worsens ascites and edema.

![Flowchart for perioperative coagulation management in the cirrhotic patient using viscoelastic testing to guide component therapy](images/cirrhosis-coag-management.png)

## Postoperative Considerations

Monitoring for hepatic decompensation, including worsening encephalopathy, jaundice, coagulopathy, and renal failure, is essential. Lactulose and rifaximin should be continued for encephalopathy prophylaxis. Hepatotoxins such as excessive acetaminophen and NSAIDs should be avoided. Hepatology should be involved early for co-management. ICU admission is recommended for CTP B and C patients after major surgery.

![Photo of a viscoelastic testing device (TEG or ROTEM) displaying a tracing with labeled parameters](images/teg-rotem-tracing.png)

## Clinical Pearls

The MELD score is the best single predictor of perioperative mortality in cirrhotic patients, and a MELD greater than 15 warrants a serious risk-benefit discussion. The INR in cirrhosis does not predict bleeding risk due to rebalanced hemostasis; viscoelastic testing should guide transfusion decisions. Cisatracurium and remifentanil are the preferred neuromuscular blocker and opioid, respectively, due to organ-independent metabolism. Maintaining hepatic blood flow is paramount: hypotension should be avoided, the lowest effective dose of volatile agents should be used, and the effects of positive-pressure ventilation on hepatic venous return should be minimized. Acute hepatitis (transaminases greater than 3 times normal) is a contraindication to elective surgery.

## References

1. Teh SH, Nagorney DM, Stevens SR, et al. Risk factors for mortality after surgery in patients with cirrhosis. *Gastroenterology*. 2007;132(4):1261-1269.
2. Northup PG, Friedman LS, Kamath PS. AGA clinical practice update on surgical risk assessment and perioperative management in cirrhosis. *Gastroenterology*. 2019;156(5):1358-1367.
3. De Pietri L, Bianchini M, Montalti R, et al. Thrombelastography-guided blood product use before invasive procedures in cirrhosis. *Hepatology*. 2016;63(2):566-573.
4. Vaja R, McNicol L, Siber I. Anaesthesia for patients with liver disease. *Contin Educ Anaesth Crit Care Pain*. 2010;10(1):15-19.