🔵 Anesthetic Goals in Chronic Liver Disease (CLD)

Chronic liver disease presents a multi-system challenge to anesthesiologists. Anesthetic management must balance hepatic reserve, coagulopathy, portal hypertension, renal function, metabolic derangements, and the impact of anesthesia on hepatic perfusion.

🔹 1. Preoperative Goals

✅ A. Full Systemic Evaluation

• Child-Pugh and MELD score: Assess hepatic functional reserve.
• Nutritional status: Commonly malnourished → ↑ drug sensitivity, delayed wound healing.
• Hepatic encephalopathy: Grade it; correct precipitating factors.
• Ascites: May need paracentesis, albumin replacement if >5L removed.
• Varices: Increased aspiration risk; evaluate EGD status.
• Renal function: Rule out hepatorenal syndrome (HRS).
• Pulmonary: Look for hepatopulmonary syndrome, portopulmonary hypertension, pleural effusions.

✅ B. Correctable Issues

• Electrolyte imbalances: Especially hyponatremia, hypokalemia, metabolic alkalosis.
• Hypoglycemia or hyperglycemia
• Coagulopathy: Optimize INR, platelets. May need Vitamin K, FFP, platelets.
• Infections: Increased risk due to immune dysfunction.

🔹 2. Intraoperative Goals

🎯 PRINCIPLE: Maintain hepatic perfusion, avoid further liver insult, ensure metabolic and hemostatic stability.

✅ A. Hemodynamic Goals

Invasive monitoring: Arterial line, CVP. Consider TEE or advanced CO monitoring in major surgery or liver transplant.

✅ B. Respiratory Goals

• Avoid hypoxia and hypercarbia → both reduce hepatic blood flow.
• Use lung-protective strategies (especially if pulmonary shunts present).
• Watch for hepatopulmonary syndrome: Vasodilation + shunting → hypoxemia.
• Avoid high PEEP → ↓ venous return, ↓ hepatic perfusion.

✅ C. Neurological Goals

• Assess and monitor encephalopathy.
• Avoid CNS depressants unless ventilated.
• Use short-acting agents (propofol, remifentanil) to avoid prolonged sedation.

✅ D. Coagulation Goals

• Monitor with TEG or ROTEM if available.
• INR and platelet count alone may not reflect bleeding risk.
• Correct platelets <50,000/mm³, INR >1.5 for invasive procedures.
• Prefer cell salvage and antifibrinolytics (e.g., TXA) in bleeding.
• Avoid HES and other synthetic colloids (may worsen coagulopathy).

✅ E. Drug Handling Goals

Key challenge: altered pharmacokinetics

• ↓ Hepatic metabolism (esp. Phase I reactions → oxidation, reduction, hydroxylation)
• ↓ Albumin → ↑ free drug concentration
• ↓ CYP450 activity
• ↓ Plasma cholinesterase → prolonged suxamethonium effect

✅ F. Fluid and Electrolyte Goals

• Use balanced crystalloids (e.g., Plasmalyte).
• Avoid NS → risk of hyperchloremic acidosis.
• Avoid HES, gelatin colloids.
• Use Albumin for:
• Large-volume paracentesis
• Spontaneous bacterial peritonitis
• Circulatory support in HRS
• Maintain normoglycemia
• Maintain normal K+, Na+, Mg²+

🔹 3. Postoperative Goals

✅ A. Monitoring

• ICU-level care if major surgery.
• Watch for:
• Hepatic decompensation
• AKI
• Bleeding
• Encephalopathy
• Respiratory failure

✅ B. Pain Management

• Avoid NSAIDs (risk of bleeding, renal injury).
• Use opioids cautiously (risk of encephalopathy).
• Consider epidural only if coagulopathy ruled out.
• Use regional blocks (e.g., TAP) if coagulation normal.

✅ C. DVT Prophylaxis

• Despite elevated INR, cirrhotic patients are prothrombotic.
• Use mechanical prophylaxis.
• Consider pharmacologic prophylaxis postoperatively if bleeding risk is acceptable.

🔹 Special Considerations

🔚 Summary Table of Anesthetic Goals in CLD