Cirrhosis & advanced liver disease

Top concerns

1. 1.Quantify risk first: Child-Pugh/MELD correlate strongly with perioperative mortality — elective surgery in decompensated cirrhosis warrants a real risk conversation
2. 2.Coagulation is 'rebalanced,' not just anticoagulated: INR poorly predicts bleeding — viscoelastic testing (TEG/ROTEM) guides products better
3. 3.Ascites: aspiration risk, reduced FRC, and drainage/fluid-shift planning
4. 4.Drug handling: ↓albumin (higher free fractions), ↓clearance — titrate everything; cisatracurium for relaxation
5. 5.Encephalopathy precipitants live in your syringe tray: sedatives, hypokalemia, constipation — minimize benzodiazepines
6. 6.Portal hypertension: varices (careful with gastric instrumentation), splanchnic hemodynamics, hepatorenal fragility — maintain renal perfusion

Drug do's and don'ts

• AVOIDBenzodiazepines— Encephalopathy precipitant with prolonged effect.
• PREFERCisatracurium— Organ-independent elimination.
• PREFERRemifentanil— Esterase metabolism — predictable offset despite hepatic failure.
• CAUTIONAcetaminophen (reduced total daily dose)— Not forbidden — commonly capped ~2 g/day in cirrhosis.

Airway & positioning

• Tense ascites → RSI-style precautions and reduced pulmonary reserve
• Careful gastric tubes/TEE decisions with known varices

Pearls

• A normal INR in cirrhosis is not hemostatic reassurance, and a high one is not necessarily bleeding risk — think rebalanced.
• The liver patient's kidney is the canary: protect MAP and avoid nephrotoxins.

Suggested reading

• Stoelting's Anesthesia and Co-Existing Disease, 8e
• Miller's Anesthesia, 9e

Educational quick-reference only — defer to clinical judgment, institutional protocols, and the primary texts above.