How would you assess a patient for a incisional hernia repair who has cirrhosis?
General anaesthetic considerations
- Consider risk of conservative management of the hernia
- Consider the underlying cause of the cirrhosis and its prognosis
- Risks of conservative treatment must weighed against the increased operative morbidity and mortality
- Surgery is contraindicated in patients with Child-Pugh Class C, acute hepatitis, severe coagulopathy, severe chronic hepatitis, or severe extrahepatic manifestations of liver disease (eg, acute renal failure, hypoxia, cardiomyopathy).
- Avoid surgery if possible in patients with a MELD score >8 OR Child-Pugh Class B
- Beware sedatives and neuromuscular blocking agents.
- Optimize medical therapy for patients with cirrhosis.
- Correct coagulopathy with vitamin K and FFP to achieve prothrombin time within 3 seconds of normal.
- The goal platelet count is >50-100 X 103/L.
- Minimize ascites to decrease risk of abdominal-wall herniation, wound dehiscence, and problems with ventilation.
- Address nutritional needs.
- Monitor renal function.
- Monitor and correct electrolyte abnormalities, especially hypokalemia and metabolic alkalosis.
Risk assessment
|
Component
|
Scoreb
|
|
1 point
|
2 points
|
3 points
|
|
Total bilirubin concentration (µmol/l)c
|
<34
|
34-50
|
>50
|
|
Serum albumin concentration (g/l)
|
>35
|
28-35
|
<28
|
|
International normalized ratio
|
<1.7
|
1.7-2.2
|
>2.2
|
|
Ascites
|
None
|
Controlled with medication
|
Treatment-refractory
|
|
Encephalopathy
|
None
|
Grade I-II (or controlled with medication)
|
Grade III-IV (or treatment-refractory)
|
Class A = 5-6 points,
Class B = 7-9 points
Class C = 10-15 points.
Preoperative assessment
|
Clinical manifestation
|
Management considerations
|
|
Nutritional status
|
Maintenance of an adequate protein intake (1–1.5 g/kg per day)
Promotion of a balanced diet
|
|
Coagulopathy
|
Vitamin K supplementation
Fresh, frozen plasma transfusions
Intravenous administration of cryoprecipitate
Intravenous administration of recombinant factor VIIa
Platelet transfusions ( hypersplenism)
|
|
Ascites
|
Paracentesis with analysis of ascitic fluid for evidence of infection
Dietary sodium restriction (<2 g daily)
Oral diuretic therapy with spironolactone and/or furosemide
Fluid restriction (if sodium concentration is <120 mmol/l)
Avoidance of excessive saline administration
Avoidance of NSAIDs
|
|
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 ~3–4 bowel movements per day
Administration of nonabsorbable antibiotics
Decreased protein intake
|
|
Pulmonary hepatic vascular disorders
|
Supportive care
Supplemental oxygen
|
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