This document discusses preoperative assessment and optimization of patients with cirrhosis undergoing non-transplant surgery. It covers evaluating factors like CTP score, MELD score, portal hypertension, alcohol use, and coagulation status. It recommends using multiple risk stratification methods. Optimization includes treating ascites and encephalopathy, avoiding NSAIDs, and using acetaminophen cautiously. Neuraxial anesthesia may be considered if coagulation is normal.

1. Pre Operative Assessment &
Optimization of Patient with CLD
for Non Transplant Surgery
By Dr. Rohit K. Saini
Moderator – Dr. Gaurav

2. Overview
• Patient with Cirrhosis are at increased risk of Perioperative
morbidity & mortality (2 – ≥10 times higher) than patients
without Cirrhosis.
• They pose substantial perioperative challenge to
Anesthesiologists.
• Preoperative evaluation - focus on identifying which factors
are present and how to optimize them before the planned
operation.

3. Multisystem Involvement

4. Preoperative Evaluation
• Clinical Evaluation
• Lab studies
• Imaging
• Risk assessment
• Other measures of Hepatic function

6. Risk assessment
• ASA class
• CTP score
• MELD / MELD Na
• Mayo Clinic risk score
• Type of Surgery
• Urgency of Surgery

7. Other measures of Hepatic function
• ICG clearance
• Galactose elimination capacity
• Rate of metabolism of Lidocaine to MEGS
(mono ethyl glycine xylidide)
• Aminopyrine breath test
These tests have no prediction, prognostic and practical utility superior to
other tests. So not used routinely in clinical practice.

8. There is no single definitive risk
stratification system to determine
operative risk in patients with
cirrhosis and recommend using
multiple methods.

10. CTP Score
Long standing & most widely used tool for
assessment of disease severity and overall
mortality risk in patients with Cirrhosis.

11. CTP score
Limitations :
• Variation in assessment of presence & severity of
Ascites and Encephalopathy.
• No. of risk factors not included in it, like Portal HTN
(which is independent predictor).
• Any elevation in bilirubin level above 3 mg/dL
contributes to the same score in the calculation of
the CTP class (ceiling effect).

12. MELD Score
• Originally developed to predict 3 month survival in
patients undergoing TIPS procedure.
• Now most commonly used for prioritising patient for
LT.
• Also validated in assessing prognosis in Cirrhosis.
Uses 3 lab tests : Creatinine, Bilirubin, INR
3.78 × ln [S. Bil (mg/dL)] + 11.2 × ln [INR] + 9.57 × ln [S. Creat (mg/dL)] + 6.43

13. In general, there is good correlation between CTP and
MELD scoring in prediction.
Model for End-Stage Liver Disease scores of <10, 10 to
14, and >14 are comparable to CTP classes A, B, and C,
respectively.

14. Every 1% increase in mortality for each MELD point
until 20 and a 2% increase in mortality with each MELD
point after 20

15. Relationship between MELD score and
relative risk of postoperative mortality
at (A) 30 days, (B) 90 days, and (C) 1
year. (Linear Relationship)

17. Mayo model Score
Mayo postoperative mortality risk prediction
model was designed specifically to predict
mortality after non-transplant surgery for
patients with cirrhosis of the liver:
• Age
• ASA classification
• MELD score

18. J Clin Transl Hepatol 2019;7(1):9–14.
doi: 10.14218/JCTH.2018.00043

19. 2012

20. Surgery related
• Emergency surgical procedures confers 4 to 5 times
higher mortality than elective surgeries.
• Laparascopic surgeries to be performed whenever
possible.

22. 2019

23. Portal HTN is the independent predictor of risk of
mortality with sensitivity of 83.6% and specificity of
92.8%.

24. AUDIT - C
Acute alcoholic hepatitis is a C/I to surgery because of the high
risk of postop hepatic failure & death. Also withdrawal
symptoms , Delirium tremens.
Alcohol Use Disorders Identification Test-Consumption (AUDIT-C)
– scores ≥5 (out of 12) significantly more postoperative
complications.
Complication - 5.6% in those with AUDIT-C scores 1–4 and 14% in
those with scores 11–12.
2019

27. Platelet Transfusion
• Prophylactic transfusions unlikely to be beneficial and may
expose to volume overload, transfusions or unexpected
thrombosis.
• Recently, thrombopoietin analogues (romiplostim) and
receptor agonists (eltrombopag, avatrombopag, and
lusutrombopag) developed for thrombocytopenia due to ITP.
• Only avatrombopag and lusutrombopag approved for the
general thrombocytopenia related to liver disease.

28. Platelet Transfusion
• Eltrombopag is also labeled for use in patients with
cirrhosis due to chronic hepatitis C to allow
increasing platelet counts during antiviral therapy
with interferon.

29. Pain Management in Cirrhosis
• Acetaminophen – misconception not to use.
Recommendation – Total daily dose ≤2 gm.
• NSAID.s – Contraindicated. Topical NSAID.s can be
considered (fewer systemic SE).
• Gabapentin/Pregabalin – minimal hepatic
metabolism with unchanged drug excretion from the
kidney . Consider Gabapentin first line nonopioid
agent for neuropathic pain.
contd.

30. Pain Management in Cirrhosis
• TCA - Nortriptyline & Desipramine are generally
recommended over amitriptyline and imipramine
because of decreased sedation effects.
• Opioids – In general, d/t increased t1/2 in cirrhosis,
IR formulations should be used & ER formulations
avoided, and extended dosing intervals should be
prescribed
2018

31. Pain Management in Cirrhosis
• Neuraxial Anesthesia – If Coagulation profile is
normal.
• Regional Analgesia in the form of local infiltration or
PN block (TAP or RSB) can be considered in selected
patients (Opioid sparing effect). It can be included as
an adjunct in multimodal Analgesia.