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Perioperative care in acute liver failure: An anaesthesiologist perspective in the operating theatre

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Abstract

Acute liver failure (ALF) is a life-threatening condition characterized by rapid liver function deterioration, necessitating a multidisciplinary approach for optimal perioperative care. This comprehensive review focuses on the critical role of the anaesthesiologist throughout the preoperative, intraoperative, and postoperative phases, addressing the unique challenges posed by ALF. The article begins with an exploration of ALF, underlining the urgency of timely referral to specialized hepatology centres. Liver transplantation emerges as a life-saving intervention, and the complex decision-making process is discussed, emphasizing the need for a multidisciplinary team to assess transplantation candidacy based on established prognostic criteria. In the preoperative phase, the review stresses the importance of early engagement with tertiary liver centres for timely referrals and identifies patients suitable for transplantation. Safe transport protocols are detailed, highlighting the meticulous planning required for the secure transfer of ALF patients between healthcare facilities. The intraoperative management section delves into the anaesthesiologist’s key concerns, including neurological status, sepsis, acute kidney injury, body mass index, and preoperative fasting. Hemodynamic stability, fluid management, and coagulation balance during surgery are emphasized, with insights into anaesthesia techniques, vascular access, monitoring, and hemodynamic management tailored to the challenges posed by ALF patients. The postoperative care is thoroughly examined covering neurological, hemodynamic, metabolic, renal, and nutritional aspects. Management of ALF involves multidisciplinary team, including nephrology for continuous renal replacement therapy, transfusion medicine for plasma exchange, critical care for overall patient care, nutritionists for ensuring adequate nutrition, and hepatologists as the primary guides. In conclusion, the review recognizes the anaesthesiologist as a linchpin in the perioperative care of ALF patients. The integration of safe transport protocols and multidisciplinary approach is deemed crucial for navigating complexities of ALF, contributing to improved patient outcomes. This article serves as an invaluable resource for gastroenterologist and intensivists, enhancing their understanding of the anaesthesiologist’s indispensable role in the holistic care of ALF patients in an ever-evolving healthcare landscape.

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References

  1. Bernal W, Hyyrylainen A, Gera A, et al. Lessons from look-back in acute liver failure? A single centre experience of 3300 patients. J Hepatol. 2013;59:74–80. https://doi.org/10.1016/j.jhep.2013.02.010.

    Article  PubMed  Google Scholar 

  2. Wendon J, Cordoba J, Dhawan A, et al. EASL Clinical Practical Guidelines on the management of acute (fulminant) liver failure. J Hepatol. 2017;66:1047–81. https://doi.org/10.1016/j.jhep.2016.12.003.

    Article  PubMed  Google Scholar 

  3. Bacon BR, et al. Comprehensive clinical hepatology. St. Louis, MO; London: Elsevier Mosby. 2006. https://doi.org/10.1016/B978-0-323-03675-7.X5001-X .

  4. Rajaram P, Subramanian R. Acute liver failure. Semin Respir Crit Care Med. 2018;39:513–22. https://doi.org/10.1055/s-0038-1673372.

    Article  PubMed  Google Scholar 

  5. Slack AJ, Auzinger G, Willars C, et al. Ammonia clearance with haemofiltration in adults with liver disease. Liver Int. 2014;34:42–8. https://doi.org/10.1111/liv.12221.

    Article  CAS  PubMed  Google Scholar 

  6. Aggarwal S, Mazariegos V.G, Blisard D. Acute liver failure: perioperative management. In: Subramaniam K, Sakai T. (eds) Anaesthesia and perioperative care for organ transplantation. 1st ed. Springer, New York. 2016;411–26. https://doi.org/10.1007/978-1-4939-6377-5_32.

  7. O’Grady J. Timing and benefit of liver transplantation in acute liver failure. J Hepatol. 2014;60:663–70. https://doi.org/10.1016/j.jhep.2013.10.024.

    Article  PubMed  Google Scholar 

  8. Biswas S, Shalimar. Liver transplantation for acute liver failure- indication, prioritization, timing, and referral. J Clin Exp Hepatol. 2023 13:820–34. https://doi.org/10.1016/j.jceh.2023.01.008.

  9. Bernal W, Wendon J. Liver transplantation in adults with acute liver failure. J Hepatol. 2004;40:192–7. https://doi.org/10.1016/j.jhep.2003.11.020.

    Article  PubMed  Google Scholar 

  10. Sheikh MF, Unni N, Agarwal B. Neurological monitoring in acute liver failure. J Clin Exp Hepatol. 2018;8:441–7. https://doi.org/10.1016/j.jceh.2018.04.013.

    Article  PubMed  PubMed Central  Google Scholar 

  11. Vaquero J, Fontana RJ, Larson AM. Complications and use of intracranial pressure monitoring in patients with acute liver failure and severe encephalopathy. Liver Transpl. 2005;11:1581–9. https://doi.org/10.1002/lt.20625.

    Article  PubMed  Google Scholar 

  12. Rabinowich L, Wendon J, Bernal W, Shibolet O. Clinical management of acute liver failure: results of an international multi-center survey. World J Gastroenterol. 2016;22:7595–603. https://doi.org/10.3748/wjg.v22.i33.7595.

    Article  PubMed  PubMed Central  Google Scholar 

  13. Karvellas CJ, Fix OK, Battenhouse H, Durkalski V, Sanders C, Lee WM. Outcomes and complications of intracranial pressure monitoring in acute liver failure: a retrospective cohort study. Crit Care Med. 2014;42:1157–67. https://doi.org/10.1097/CCM.0000000000000144.

    Article  PubMed  PubMed Central  Google Scholar 

  14. Jalan R. Intracranial hypertension in acute liver failure: pathophysiological basis of rational management. Semin Liver Dis. 2003;23:271–82. https://doi.org/10.1055/s-2003-42645.

    Article  PubMed  Google Scholar 

  15. Strauss GI, Christiansen M, Møller K, Clemmesen JO, Larsen FS, Knudsen GM. S-100b and neuron-specific enolase in patients with fulminant hepatic failure. Liver Transpl. 2001;7:964–70. https://doi.org/10.1053/jlts.2001.28742.

    Article  CAS  PubMed  Google Scholar 

  16. Cardoso FS, Gottfried M, Tujios S, Olson JC, Karvellas CJ. US Acute Liver Failure Study Group Continuous renal replacement therapy is associated with reduced serum ammonia levels and mortality in acute liver failure. Hepatology. 2018;67:711–20. https://doi.org/10.1002/hep.29488.

    Article  CAS  PubMed  Google Scholar 

  17. Murphy N, Auzinger G, Bernel W, Wendon J. The effect of hypertonic sodium chloride on intracranial pressure in patients with acute liver failure. Hepatology. 2004;39:464–70. https://doi.org/10.1002/hep.20056.

    Article  CAS  PubMed  Google Scholar 

  18. Aziz R, Price J, Agarwal B. Management of acute liver failure in intensive care. BJA Education. 2021;21:110–6. https://doi.org/10.1016/j.bjae.2020.11.006.

    Article  PubMed  PubMed Central  Google Scholar 

  19. Van Den Broek MAJ, Damink SWMO, Winkens B, Broelsch CE, Malagó M, Paul A, et al. Procalcitonin as a prognostic marker for infectious complications in liver transplant recipients in an intensive care unit. Liver Transpl. 2010;16:402–10. https://doi.org/10.1002/lt.21987.

    Article  PubMed  Google Scholar 

  20. Betrosian AP, Agarwal B, Douzinas EE. Acute renal dysfunction in liver diseases. World J Gastroenterol. 2007;13:5552–9. https://doi.org/10.3748/wjg.v13.i42.5552.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  21. Brezeanu LN, Brezeanu RC, Diculescu M, Droc G. Anaesthesia for liver transplantation: an update. J Crit Care Med. 2020;2020(6):91–100. https://doi.org/10.2478/jccm-2020-0011.

    Article  Google Scholar 

  22. Aniskevich S, Scott CL, Ladlie BL. The practice of fast-track liver transplant anesthesia. J Clin Med. 2023;12:3531. https://doi.org/10.3390/jcm12103531.

    Article  PubMed  PubMed Central  Google Scholar 

  23. Haque ME, Badenoch AD, Orlov D, Selzner M, McCluskey SA. Predicting early extubation after liver transplantation: external validation and improved generalizability of a proposed fast-track score. Transplantation. 2021;105:2029–36. https://doi.org/10.1097/TP.0000000000003452.

    Article  PubMed  Google Scholar 

  24. Guerin L, Monnet X, Teboul JL. Monitoring volume and fluid responsiveness: from static to dynamic indicators. Best Pract Res Clin Anaesthesiol. 2013;27:177–85. https://doi.org/10.1016/j.bpa.2013.06.002.

    Article  PubMed  Google Scholar 

  25. Manning MW, Kumar PA, Maheshwari K, Arora H. Post-reperfusion syndrome in liver transplantation-an overview. J Cardiothorac Vasc Anesth. 2020;34:501–11. https://doi.org/10.1053/j.jvca.2019.02.050.

    Article  PubMed  Google Scholar 

  26. Fiegel M, Cheng S, Zimmerman M, et al. Postreperfusion syndrome during liver transplantation. Semin Cardiothorac Vasc Anesth. 2012;16:106–13. https://doi.org/10.1177/1089253212444791.

    Article  PubMed  Google Scholar 

  27. Semler MW, Self WH, Wanderer JP, et al. Balanced crystalloids versus saline in critically ill adults. N Engl J Med. 2018;378:829–39. https://doi.org/10.1056/NEJMoa1711584.

    Article  PubMed  PubMed Central  Google Scholar 

  28. Brown RM, Wang L, Coston TD, Krishnan NI, Casey JD, Wanderer JP, et al. Balanced crystalloids versus saline in sepsis. A secondary analysis of the SMART clinical trial. Am J Respir Crit Care Med. 2019;200:1487–95. https://doi.org/10.1164/rccm.201903-0557oc.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  29. Lee WM. Acute liver failure. Yamada’s textbook of gastroenterology. 2022;15:1889-905. https://doi.org/10.1002/9781119600206.ch90.

  30. Helbok R, Olson DM, Le Roux PD, Vespa P. Participants in the International Multidisciplinary Consensus Conference on Multimodality Monitoring. Intracranial pressure and cerebral perfusion pressure monitoring in non-TBI patients: special considerations. Neurocrit Care. 2014;21 Suppl 2:S85-S94. https://doi.org/10.1007/s12028-014-0040-6.

  31. Bernal W, Murphy N, Brown S, et al. A multicentre randomized controlled trial of moderate hypothermia to prevent intracranial hypertension in acute liver failure. J Hepatol. 2016;65:273–9. https://doi.org/10.1016/j.jhep.2016.03.003.

    Article  PubMed  Google Scholar 

  32. Nielsen N, Wetterslev J, Cronberg T, et al. Targeted temperature management at 33°C versus 36°C after cardiac arrest. N Engl J Med. 2013;369:2197–206. https://doi.org/10.1056/NEJMoa1310519.

    Article  CAS  PubMed  Google Scholar 

  33. Zivković SA. Neurologic complications after liver transplantation. World J Hepatol. 2013;5:409–16. https://doi.org/10.4254/wjh.v5.i8.409.

    Article  PubMed  PubMed Central  Google Scholar 

  34. Ely EW, Truman B, Shintani A, et al. Monitoring sedation status over time in ICU patients: reliability and validity of the Richmond Agitation-Sedation Scale (RASS). JAMA. 2003;289:2983–91. https://doi.org/10.1001/jama.289.22.2983.

    Article  PubMed  Google Scholar 

  35. Sessler CN, Gosnell MS, Grap MJ, et al. The Richmond Agitation-Sedation Scale: validity and reliability in adult intensive care unit patients. Am J Respir Crit Care Med. 2002;166:1338–44. https://doi.org/10.1164/rccm.2107138.

    Article  PubMed  Google Scholar 

  36. Berry PA, Melendez HV, Wendon JA. Postoperative care of the liver-transplant patient. Surgical Intensive Care Medicine. 2010;629–38. https://doi.org/10.1007/978-0-387-77893-8_53.

  37. Vitin AA, Tomescu D, Azamfirei L. Hemodynamic optimization strategies in anesthesia care for liver transplantation. liver cirrhosis - update and current challenges. InTech. 2017. https://doi.org/10.5772/intechopen.68416.

  38. Lee EM, Kang JK, Yun S-C, et al. Risk factors for central pontine and extrapontine myelinolysis following orthotopic liver transplantation. Eur Neurol. 2009;62:362–8. https://doi.org/10.1159/000242426.

    Article  PubMed  Google Scholar 

  39. Noble J, Terrec F, Malvezzi P, Rostaing L. Adverse effects of immunosuppression after liver transplantation. Best Pract Res Clin Gastroenterol. 2021;54–55: 101762. https://doi.org/10.1016/j.bpg.2021.101762.

    Article  PubMed  Google Scholar 

  40. Junge G, Schewior LV, Kohler S, et al. Acute renal failure after liver transplantation: incidence, etiology, therapy, and outcome. Transplant Proc. 2006;38:723–4. https://doi.org/10.1016/j.transproceed.2006.01.074.

    Article  CAS  PubMed  Google Scholar 

  41. Biancofiore G, Bindi ML, Boldrini A, et al. Intraabdominal pressure in liver transplant recipients: incidence and clinical significance. Transplant Proc. 2004;36:547–9. https://doi.org/10.1016/j.transproceed.2004.02.029.

    Article  CAS  PubMed  Google Scholar 

  42. Citerio G, Vascotto E, Villa F, Celotti S, Pesenti A. Induced abdominal compartment syndrome increases intracranial pressure in neurotrauma patients: a prospective study. Crit Care Med. 2001;29:1466–71. https://doi.org/10.1097/00003246-200107000-00027.

    Article  CAS  PubMed  Google Scholar 

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Authors and Affiliations

  1. Department of Anaesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research, Satellite Centre, Sangrur, Punjab, India

    Kashish Garg

  2. Department of Organ Transplant Anaesthesia and Critical Care, Mahatma Gandhi Medical College and Hospital, Jaipur, Rajasthan, India

    Anand Kumar Jain & Ganesh Ramaji Nimje

  3. Department of Anaesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh, India

    Kamal Kajal

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Contributions

Dr. Kashish Garg and Dr. Anand Kumar Jain helped in conceiving the original concept, original draft preparation, and its revision. Dr. Ganesh Ramaji Nimje helped in literature search and data analysis. Dr. Kamal Kajal designed the study; also helped in proof reading and revision.

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Correspondence to Kamal Kajal.

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Garg, K., Jain, A.K., Nimje, G.R. et al. Perioperative care in acute liver failure: An anaesthesiologist perspective in the operating theatre. Indian J Gastroenterol 43, 387–396 (2024). https://doi.org/10.1007/s12664-024-01575-5

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