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Perioperative considerations for patients with liver disease

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Question from the audience: What are your recommendations regarding platelet transfusion if the platelet count is less than 50,000 in a patient with liver disease?

Dr. Martin: For patients with thrombocytopenia, it is prudent to get the platelet count above 60,000 before any procedure. We will not even do a blind liver biopsy in a patient with a platelet count of less than 60,000.

Question from the audience: A study from the Annals of Surgery concludes that patients with liver disease do poorly with a hemoglobin of less than 10 g/dL. Would you transfuse aggressively before surgery?

Dr. Martin: For a patient with anemia, I don’t like to use aggressive transfusion if cirrhosis is present because the portal pressure may go up and increase the risk of variceal hemorrhage. If there is adequate time for a work-up, one can screen for varices by endoscopy. If there is evidence of overt hepatic decompensation and portal hypertension (esophageal varices, a palpable spleen, and thrombocytopenia), I wouldn’t try to get the hemoglobin much above 10 g/dL.

Question from the audience: How would you modify prophylaxis for deep vein thrombosis following hip or knee replacement surgery in patients with liver disease?

Dr. Martin: I would base it on the INR. Patients who are already mildly coagulopathic tend to be very sensitive to warfarin in the long term. For immediate perioperative prophylaxis, I would not administer anything if the patient had a platelet count below 60,000; otherwise I would probably proceed as usual.

Question from the audience: You said that we shouldn’t operate on patients with acute hepatitis, but we frequently encounter patients with drug-induced hepatitis, such as from anticholesterol drugs. These patients’ ALT and aspartate aminotransferase (AST) levels can remain elevated for 2 or 3 months. How long should we delay surgery? For example, is it dangerous to proceed with a mastectomy a month after discontinuing the drug if the liver enzymes are still around 100 U/L?

Dr. Martin: It’s worth noting that much of the literature on surgery in patients with acute viral hepatitis is 30 or 40 years old. If such a patient had a compelling reason to have surgery, you might wait until the liver enzymes were trending downward and you were confident that the patient was recovering.

Question from the audience: How do you manage patients who have varices or have had variceal bleeding in the past? Many of them are on beta-blockers, such as propranolol, which can cause hypotension intraoperatively.

Dr. Martin: The standard of care is to prescribe beta-blockers for a patient with large varices, or to ablate the varices by endoscopy, which is my practice. In general, I would discontinue propranolol on the morning of surgery. If possible, however, I would have the patient undergo endoscopy before surgery to assess the likelihood of short-term variceal bleeding. If the varices look to be at low risk of bleeding, the beta-blocker can safely be stopped. If they look to be at high risk of bleeding, the surgery should be delayed for a few weeks, if possible, so that the varices can be ablated, which usually takes two or three sessions.

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