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Anaesthesia in the patient with liver disease
In cirrhosis surgical risk rises with Child-Pugh and MELD, drugs cleared by the liver last longer, and a high INR does not predict bleeding as much as is thought — so liver-independent drugs are chosen and clotting is managed by functional tests.
Why it matters in the exam
The exam asks when elective surgery is forbidden (acute hepatitis, Child C), which drugs suit (cisatracurium, remifentanil, propofol) and which to avoid (benzodiazepines that worsen encephalopathy, repeated doses of morphine), why the INR is not routinely corrected with plasma, and what the special complications are: hepatorenal syndrome, hepatopulmonary syndrome, portopulmonary hypertension and hyponatraemia.
Cirrhosis brings a new balance in clotting: both clotting factors and natural anticoagulants are deficient, so a high INR does not necessarily mean a bleeding tendency. Large-volume drainage of ascites before surgery is accompanied by albumin (about 8 grams per litre when more than 5 litres are drained) to prevent hypotension and kidney injury. The volume of distribution of drugs grows, albumin is low so the free fraction rises, and hepatic metabolism is slow.
When choosing drugs, a relaxant cleared by Hofmann elimination (cisatracurium), an opioid broken down by esterases (remifentanil) and propofol are preferred; among the volatile agents, isoflurane, sevoflurane and desflurane preserve hepatic blood flow better than halothane. Paracetamol is allowed at a reduced dose (up to 2 grams a day), and NSAIDs are avoided because of bleeding and kidney injury. Maintaining blood pressure and hepatic blood flow during surgery is especially important, because the diseased liver is sensitive to ischaemia.
Key points
- Child-Pugh and MELD predict risk; Child C and acute hepatitis — no elective surgery.
- Cisatracurium, remifentanil and propofol suit; benzodiazepines — avoid.
- Clotting: a new balance; viscoelastic tests, not the INR alone.
- Ascites: drainage with albumin; aspiration risk.
- Paracetamol up to 2 grams a day; no NSAIDs.
Summary table
| Issue | What is done | Exam point |
|---|---|---|
| Risk assessment | Child-Pugh and MELD | Child C and acute hepatitis — postpone elective surgery |
| Drugs | Cisatracurium, remifentanil, propofol; avoid benzodiazepines | Rocuronium and vecuronium are prolonged |
| Clotting | Viscoelastic tests; vitamin K if deficient | Do not correct the INR with plasma just for the number |
| Ascites | Drainage with albumin about 8 g per litre above 5 litres | Ascites reduces FRC and raises aspiration risk |
| Lung complications | Hepatopulmonary: hypoxaemia on standing; portopulmonary: pulmonary hypertension | Severe portopulmonary hypertension greatly raises anaesthetic risk |
A free exam question
( איזה מהבאים הוא הגורם העיקרי לתחלואה ותמותה הקשורות לשחמת הכבד Cirrhosis ?) (the question as examined, in Hebrew)
- א. Hyperbilirubinemia
- ב. Portal hypertension
- ג. Hypoalbuminemia
- ד. Esophageal varices
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Sources
- Miller's Anesthesia, 9th edition (2020) — Anesthesia for Patients with Liver Disease
- AASLD Practice Guidance on the management of ascites and hepatorenal syndrome, 2021 — Large-volume paracentesis and albumin
Sources are given for further reading; the text is written afresh and not copied from them.
Reviewed by the Examqo AI Professor · 2026-11-02. The text may contain errors; when in doubt, check the source.