Anesthetic Considerations in Patients With Hepatic Failure


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Excerpt

A 48-year-old man with a history of Laennec's cirrhosis (Childs class B) and hepatitis C diagnosed 3 years previously, and with a history of thrombocytopenia and moderate/severe coagulopathy, presented for dental rehabilitation/tooth extraction secondary to dental caries. The patient had no active bleeding issues at the time of presentation. The patient had a history of ingestion of 1 pint of whiskey and a 12-pack of beer everyday for 20 years, although he stated he quit 2 years ago. He also had a history of smoking cigarettes (½ pack per day for 22 years) and was still actively smoking. He was taking regular medications of vitamin B12, 5 mg hydrocodone/500-mg acetaminophen tablets everyday, and esomeprazole (Nexium) for severe gastroesophageal reflux disease. The patient had other medical history of diverticulitis and had undergone colonoscopy with negative results. He had undergone lumbar surgery and facial surgery in the past with no complications noted. On initial presentation, the patient had known coagulopathy and platelet dysfunction. Laboratory values were obtained preoperatively and revealed mild hepatocellular damage (aspartate transaminase 110U/L, alanine transaminase 39U/L), synthetic dysfunction (bilirubin 2.2 mg/dL), mild hyperglycemia (133 mg/dL), significant coagulopathy (prothrombin time [PT] 21.2 seconds [international normalized ratio 1.8], partial prothrombin time [PTT] 32.7 seconds), and suspected thrombocytopenia. Platelet count was attempted on each of the different blood draws but was unable to be completed secondary to platelet clumping in each of the specimens. However, remarks by the laboratory indicated the numbers of platelets were judged to be decreased from normal levels based on slide analysis. This assessment appeared congruent with the patient's known coagulopathy.With the patient's known history, a type and cross was obtained preoperatively and the patient was prophylactically transfused with a 6 pack of platelets before being taken to the operating room (OR). Once in the OR, standard monitors, including oscillometric blood pressure cuff, finger probe pulse oximetry, and 5-lead electrocardiogram, were attached. The patient was preoxygenated and then induced with propofol, midazolam, and hydromorphone intravenously with smooth induction. A nasal endotracheal tube was prepared and lubricated, and nasal intubation was carefully attempted through the left nares, paying particular attention to avoiding trauma that might cause bleeding. After initially passing the endotracheal tube (ETT) through the nares, mild resistance was encountered in the area of the larynx. The ETT was carefully removed from the left nares and was found to have only a slight amount of blood tinge on the tip. However, bloody secretions were at that time noted to be emanating from the left nares, and the decision was made to abandon nasal intubation in favor of oral intubation. On direct laryngoscopy of the larynx, large quantities of blood were found to be pooling in the posterior larynx obstructing view of the vocal cords. Aggressive suctioning was undertaken with approximately 100 mL of frank bloody secretions obtained. The vocal cords were poorly visualized and required 3 attempts to correctly place the ETT. The patient experienced brief desaturations to 70%, and after intubation, the ETT was aggressively suctioned with output of approximately 100 mL of bloody secretions with a rapid improvement in oxygen saturation to 99%. Albuterol inhalers were administered through the ETT, and epinephrine/Afrin-soaked nasal pledgets were applied to the left nares by the oral surgery team. Two units of fresh-frozen plasma (FFP) were transfused at this time, and the patient eventually achieved hemostasis approximately 20 to 30 minutes later. The decision was made to carry on with the surgery, and a total of 4 teeth were extracted by the surgery team without further significant bleeding or other complications.

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