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Jean Mantz, MD, PhD Professor of Anesthesia and Critical Care

Principles of anesthesia in cirrhotic patients. Jean Mantz, MD, PhD Professor of Anesthesia and Critical Care Chairman, Department of Anesthesia and Critical Care, Beaujon University Hospital INSERM U 676 University of Paris. Anesthesia and cirrhosis. Principles of perioperative management

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Jean Mantz, MD, PhD Professor of Anesthesia and Critical Care

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  1. Principles of anesthesia in cirrhotic patients Jean Mantz, MD, PhD Professor of Anesthesia and Critical Care Chairman, Department of Anesthesia and Critical Care, Beaujon University Hospital INSERM U 676 University of Paris

  2. Anesthesia and cirrhosis • Principles of perioperative management • Anesthesia and cirrhosis in: • Liver transplantation • Liver resection • Endoscopic procedures • Conclusion

  3. Cirrhotic patients: Risk factors for perioperative morbi-mortality Ziser et al Anesthesiology 1999; 90: 42-53

  4. Cirrhotic patients: Risk factors for perioperative morbi-mortality Ziser et al Anesthesiology 1999; 90: 42-53

  5. Cirrhotic patients: Risk factors for perioperative morbi-mortality Ziser et al Anesthesiology 1999; 90: 42-53

  6. Venous compliance in cirrhosisHadengue et al, Hepatology 1992 300 mL gélatine en 3 min

  7. Fluid management Hypovolemia Fluid overload

  8. Preoperative risk evaluation • Circulatory (hyperkinetic profile with low SVR, high venous compliance, coronaropathy or cardiomoypathy, pulmonary hypertension) • Ventilatory (Hypoxemia, intrapulmonary shunt, restrictive syndrome (ascite, pleural effusion)

  9. Preoperative risk evaluation • Circulatory (hyperkinetic profile with low SVR, high venous compliance, coronaropathy or cardiomoypathy, pulmonary hypertension) • Ventilatory (Hypoxemia, intrapulmonary shunt, restrictive syndrome (ascite, pleural effusion) • Renal (hypovolemia, hepatorenal syndrome) • Cerebral (encephalopathy, cerebral edema) • Coagulation (hypo-/ hypercoagulability, fibrinolysis) • Pharmacokinetic/dynamic changes to drug effects

  10. Choice of anesthetic agents/techniques • Risks of regional anesthesia • Use intravenous anesthetics with elimination independent from cytochrome P450 activity (Propofol AIVOC, ketamine, etomidate, fentanyl, sufentanil, remifentanil, atracurium/cisatracurium) • Volatile anesthetics: desflurane/sevoflurane • Maintain hemodynamic stability +++ • MONITOR and TITRATE+++

  11. Patient Risk/benefit balance of anesthesia and surgery Anesthesiologist Surgeon Hepatologist/ Gastroenterologist

  12. Intraoperative period • Short acting anesthetics • Postoperative analgesia • Prevention of PONV • Reversal of muscle relaxants • Maintenance of normovolemia, hemoglobin levels • Prevention of awareness • Maintenance of normothermia • Maintain oxygenation • Restrictive fluid therapy • Avoid hyperglycemia • Start postoperative rehabilitation

  13. Intraoperative period • Short acting anesthetics • Postoperative analgesia • Prevention of PONV • Reversal of muscle relaxants • Maintenance of normovolemia, hemoglobin levels • Prevention of awareness • Maintenance of normothermia • Maintain oxygenation • Restrictive fluid therapy • Avoid hyperglycemia • Start postoperative rehabilitation

  14. Cirrhosis and coagulation abnormalities T. Lisman et al. J Hepatol 2002;37:280-7

  15. Hepatology 2006,44:53-61

  16. Cirrhosis Coagulation abnormalities Hemorrhage

  17. Cirrhosis Coagulation abnormalities Portal hypertension ? Hemorrhage

  18. Postoperative rehabilitation Multimodal analgesia Early extubation Early removal of tubes and catheters Early mobilization Thromboprophylaxis Early enteral nutrition Hydratation

  19. Postoperative rehabilitation Multimodal analgesia Early extubation Early removal of tubes and catheters Early mobilization Thromboprophylaxis Early enteral nutrition Hydratation

  20. Liver transplantation in Beaujon: recipients

  21. 2005-2007 (n=215) 2001-2004 (n=242) 1997-2000 (n=212) 1993-1996 (n=77) 1989-1992 (n=51)

  22. Cirrhosis (n=416) Others (n=72) Fulminans (n=139) HCC (n=248) Survival / indications

  23. Anesthesia for endoscopic procedures. • High risk anesthesia +++ • Outside the OR • Inhalation of gastric content • Obstructive hypoxemia • Hemorrhage and perforation • Pulmonary hypertension

  24. Indications for endotracheal intubation • Esophageal varices treatment (inhalation risk+++) • Radiofrequency (painful procedures) • Other indications: • Long duration procedure (> 1h)) • Comorbidities (obesity, major ascite, diabetic dysautonomia)

  25. Conclusion • Cirrhotic patients are at high risk of postoperative morbi-mortality • Discuss the risk/benefit balance of surgery and anesthesia • Maintain hemodynamic stability (monitor, titrate) • There is no « minor » anesthesia

  26. Thank you for your kind attention

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