Anesthesia for Patients With Liver Disease

Context:

Liver plays an important role in metabolism and physiological homeostasis in the body. This organ is unique in its structure and physiology. So it is necessary for an anesthesiologist to be familiar with various hepatic pathophysiologic conditions and consequences of liver dysfunction.

Evidence Acquisition:

We searched MEDLINE (Pub Med, OVID, MD Consult), SCOPUS and the Cochrane database for the following keywords: liver disease, anesthesia and liver disease, regional anesthesia in liver disease, epidural anesthesia in liver disease and spinal anesthesia in liver disease, for the period of 1966 to 2013.

Results:

Although different anesthetic regimens are available in modern anesthesia world, but anesthetizing the patients with liver disease is still really tough. Spinal or epidural anesthetic effects on hepatic blood flow and function is not clearly investigated, considering both the anesthetic drug-induced changes and outcomes. Regional anesthesia might be used in patients with advanced liver disease. In these cases lower drug dosages are used, considering the fact that locally administered drugs have less systemic effects. In case of general anesthesia it seems that using inhalation agents (Isoflurane, Desflurane or Sevoflurane), alone or in combination with small doses of fentanyl can be considered as a reasonable regimen. When administering drugs, anesthetist must realize and consider the substantially changed pharmacokinetics of some other anesthetic drugs.

Conclusions:

Despite the fact that anesthesia in chronic liver disease is a scary and pretty challenging condition for every anesthesiologist, this hazard could be diminished by meticulous attention on optimizing the patient’s condition preoperatively and choosing appropriate anesthetic regimen and drugs in this setting. Although there are paucity of statistics and investigations in this specific group of patients but these little data show that with careful monitoring and considering the above mentioned rules a safe anesthesia could be achievable in these patients.     

Technics of locoregional anesthesia of the lower limb

Regional anesthesia represents a selective method for surgery of the lower limbs because of its simplicity and its handiness. The various techniques of regional anesthesia are analysed with their risks and benefits. Epidural and spinal anesthesia represent safe and simple methods. Moreover, epidural anesthesia enables postoperative analgesia by means of a continuous infusion of local anesthetics or the injection of narcotics. Nervous blocks of the lower limbs represents also safe techniques especially for elderly patients and for day-case surgery. Intravenous regional anesthesia does not represent an usefull technique because of the possible toxicity due to a great volume of local anesthetic drugs.     

Cardiac catheterization in the patient with history of allergy to local anesthetics

Patients with a history of allergic reactions to local anesthetic drugs present a difficult problem during evaluation for cardiac catheterization procedures. In the worst cases the procedure may be deferred, or even performed without local anesthesia. In the vast majority of patients an acceptable agent for safe local anesthetic use can be found. Skin testing beginning with very dilute solutions of preservative-free local anesthetic agent may be administered easily. This report describes the practical aspects of skin testing and local anesthetic agent selection in patients with a history of allergic reaction to local anesthetic drugs.     

The effect of different types of anesthesia on digitalis toxicity

This investigation was undertaken in order to determine whether or not the type of anesthetic agent used modified the cardiotoxicity of either ouabain or acetylstrophanthidin. Ouabain toxicity was greater in animals anesthetized with chloralose and urethane than it was in animals anesthetized with pentobarbital. The toxicity of acetylstrophanthidin was the same under both types of anesthesia. It is suggested that these results can be explained by an interplay between differences in the pharmacological actions of the digitaloid substances studied and differences in the pharmacological actions of the anesthetics under question.The results of this study are significant for two reasons. They reinforce the importance of carefully choosing an anesthetic agent(s). All anesthetics do not produce identical pharmacological actions. Drugs that produce anesthesia can modify an animal's response to other drugs. There is a need for more information on the interaction between anesthetics and other drugs. This has clinical as well as experimental applicability. The differences between anesthetic agents with regard to interactions with catecholamines have been long recognized.^26,27 However, there appears to be little information on such differences between anesthetics with regard to other drugs.This study also points out the need for further study of the specific pharmacological actions of different digitaloid substances. It appears as though different cardenolides may have different potentials for increasing sympathetic activity. With further study, other differences may be found. The existence of differences in the pharmacological actions of different cardiac glycosides should increase the chances of finding a therapeutically useful cardioactive steroid that produces less toxicity than the agents that are currently in use. For example, the finding of a difference between digitaloid substances in ability to increase sympathetic outflow would improve the possibility of the development of a cardiotonic digitaloid substance that has little ability to increase sympathetic outflow. The new compound should have less potential for producing cardiac arrhythmias. Such a substance might be expected to be very useful clinically because the margin of safety should be larger than that of a similar compound that produces a significant increase in sympathetic outflow in addition to its direct positive inotropic effects.     

Accident during local anesthesia in a patient with antiarrhythmic therapy]

A side reaction of antiarrhythmic treatment in a 18-year-old patient with congestive cardiomyopathy is reported. During treatment with high doses of aprindine cerebral convulsions occurred. After ceasing the medication temporarily, a pacemaker revision was done in local anesthesia. Cerebral convulsions reappeared after injection of the local anesthetic. The patient died due to cardiac arrest. It is discussed that some amount of the local anesthetic agent (mepivacaine) was absorbed from the tissue elevating the blood level of local anesthetic drugs (aprindine and mepivacine) into the toxic range, thus producing cerebral convulsions, augmenting the stimulation threshold and depressing the automaticity of the heart. It is urged that antiarrhythmic treatment should be stopped before local anesthesia will be performed.     

Review on sedation for gastrointestinal tract endoscopy in children by non-anesthesiologists

AIM: To present evidence and formulate recommendations for sedation in pediatric gastrointestinal(GI) endoscopy by non-anesthesiologists.METHODS: The databases MEDLINE, Cochrane and EMBASE were searched for the following keywords "endoscopy, GI", "endoscopy, digestive system" AND "sedation", "conscious sedation", "moderate sedation", "deep sedation" and "hypnotics and sedatives" for publications in English restricted to the pediatric age. We searched additional information published between January 2011 and January 2014. Searches for(upper) GI endoscopy sedation in pediatrics and sedation guidelines by non-anesthesiologists for the adult population were performed. RESULTS: From the available studies three sedation protocols are highlighted. Propofol, which seems to offer the best balance between efficacy and safety is rarely used by non-anesthesiologists mainly because of legal restrictions. Ketamine and a combination of a benzodiazepine and an opioid are more frequently used. Data regarding other sedatives, anesthetics and adjuvant medications used for pediatric GI endoscopy are also presented.CONCLUSION: General anesthesia by a multidisciplinary team led by an anesthesiologist is preferred. The creation of sedation teams led by non-anesthesiologists and a careful selection of anesthetic drugs may offer an alternative, but should be in line with national legislation and institutional regulations.     

Leberchirurgische Eingriffe aus an?sthesiologischer Sicht

Liver surgery is complex and is a major abdominal procedure. The preoperative assessment is essential and allows optimization of renal function and coagulation. Because 50% of major perioperative complications are due to cardiovascular events, patients undergoing liver surgery should be evaluated according to the recommendations of the American Heart Association. The anesthesiologist should actively search for clinical signs of liver cirrhosis since many manifestations thereof directly affect anesthetic practice. The pharmacology of many medications, including anesthetics, is difficult to predict in patients with cirrhosis. Hence, all medications should be carefully titrated to their clinical effects. For anesthetic maintenance, modern halogenated ethers should be preferred. Optimization of liver perfusion during the critical intraoperative phase is one of the anesthesiologist’s most important tasks. Whenever possible, thoracic epidural anesthesia/analgesia should be used for optimal postoperative pain therapy. This allows early mobilization of the patient and also helps prevent pulmonary complications and thrombosis.     

Anesthesia

Conclusion Care of the medical patient with surgical disease depends on careful evaluation by the surgeon, the anesthesiologist, and the internist. Effective communication and shared information should optimize perioperative management. We have provided a review of anesthetic agents and methods to illustrate expected perioperative changes in physiology that occur with anesthesia. Postoperative complications and side effects of general and regional anesthetic methods have been discussed. With this knowledge the internist can plan for optimal pre-operative medical intervention, provide advice to the anesthesiologist on how anesthesia may affect the patient’s medical condition, and assist in postoperative diagnosis and management of complications. Received from the Department of Medicine, Division of General Internal Medicine, University of Texas Health Science Center at San Antonio and Audie L. Murphy Memorial Veterans Hospital, San Antonio, Texas.     

Stapled Hemorrhoidectomy Under Local Anesthesia: Tips and Tricks

Stapled hemorrhoidectomy—a new, evolving technique—is considered to be safe and painless. General and spinal anesthesia are the “gold standard” anesthetic techniques for the procedure. The stapled hemorrhoidectomy under local anesthesia is described. Emphasis is given in few tips and tricks for safe and successful application of the local anesthesia.     

Halothane: Is there still any place for using the gas as an anesthetic?

The fluorinated hydrocarbons that are used for anesthesia are derived from ether. Although they have many benefits, there are several side effects of these drugs, including untoward hepatic effects. Whether the use of halothane gas can be revitalized is unknown. Introducing nanocarriers inside the halothane molecule can increase its benefits as an anesthetic in the lungs and cardiovascular system and prevent exposure to the liver. The findings of new fields, such as cancer therapy, and anesthetic agents, such as propofol, can improve the quality of the drug using nanomedicine.     

Sinus pause during nerve integrity monitoring tube insertion following anesthetic induction with a low-dose neuromuscular blocking agent: A CARE-compliant case report

Rationale:Nerve integrity monitoring (NIM) tubes are commonly used in thyroid surgery to prevent recurrent laryngeal nerve injury. To achieve the optimal electromyographic signal for NIM as intraoperative neural monitoring (IONM), the neuromuscular blocking agent (NMBA) dose should be low. The use of a low-dose NMBA increases the anesthetic and analgesic agent dose required to attenuate the laryngeal reflex during intubation. In addition, since the NMBA onset time is delayed, depending on the situation, anesthesia may become excessively deep or shallow before intubation.Patient''s concern:A 51-year-old woman scheduled for thyroid lobectomy received 0.3 mg/kg of rocuronium. Three minutes later, when the NIM tube was inserted through the vocal cord, the patient''s heart rate (HR) was undetectable for 2 seconds.Diagnosis:We suspected that the use of a high-dose anesthetic agent and remifentanil or the laryngocardiac reflex induced the sinus pause.Interventions:To maintain the anesthetic depth, we administered 6 vol% of desflurane. Because the patient''s systolic blood pressure was 70 mmHg and HR was 30 beats/min, we discontinued the remifentanil infusion and administered 8 mg of ephedrine.Outcomes:The patient''s vital signs recovered to normal levels. Subsequently, there were no episodes of bradycardia or arrhythmia.Conclusion:Sinus pause or severe bradycardia may occur due to the laryngocardiac reflex or the administration of a high-dose anesthetic and analgesic agent during tracheal intubation in patients who received a low-dose NMBA for IONM induction using an NIM tube. Anesthesiologists should be aware of these risks and take precautions to maintain adequate anesthesia, be prepared to administer vasoactive drugs to increase the blood pressure and HR if needed, and, if possible, intravenously administer lidocaine to attenuate the laryngeal reflex during intubation.     

The shape of the buttocks

Recognition of the different shapes of the buttocks will help surgeons to appropriately select patients for anorectal surgery. Basically, there are three types of buttocks. In Type A, the mounds of the buttock make a low and gentle slope with the anal verge. In Type B, the mounds of the buttock are high and rise almost straight up from the anal verge. In Type C, the anus is located more anteriorly than normally. Patients with Type A buttocks are ideal candidates to use local anesthesia for hemorrhoidectomy and lateral internal sphincterotomy because it is easy to infiltrate the anesthetic agent into the anal canal. With Type C, this is somewhat more difficult, but no significant problem exists. For Type B buttocks, general or spinal anesthesia is recommended. For Types A and C buttocks, a lithotomy position will give an excellent exposure of the anorectal lumen for stripping the mucosa and submucosa. For Type B buttocks, a prone jack-knife position gives the best exposure.     

Prospective evaluation of anesthetic technique for anorectal surgery

PURPOSE: Deep intravenous sedation plus local anesthesia for anorectal surgery in the prone position is used frequently at our institution, but is not widely accepted because of concerns regarding airway management. The purpose of this study was to prospectively evaluate the safety and efficacy of this anesthetic technique for anorectal surgery. METHODS: Data were collected prospectively on 413 consecutive patients (mean age, 47 years; mean weight, 80 kg) undergoing anorectal surgical procedures. RESULTS: Of the 389 patients who underwent anorectal procedures in the prone position, 260 (67 percent) received intravenous sedation plus local anesthesia, 125 (32 percent) received regional anesthesia (spinal or epidural), and 4 (1 percent) received general endotracheal anesthesia. Of the 24 patients who underwent anorectal procedures in the lithotomy position, 13 (54 percent) received intravenous sedation plus local anesthesia, 2 (8 percent) received regional anesthesia, 2 (8 percent) received general endotracheal anesthesia, and 7 (29 percent) received mask inhalational anesthesia. Forty-two adverse events attributable to the anesthetic occurred in 18 patients: nausea and vomiting (n = 17), transient hypotension, bradycardia, or arrhythmia (n = 8), transient hypoxia or hypoventilation (n = 7), urinary retention (n = 6), and severe patient discomfort (n = 2). These complications occurred in 4 percent (10/273) of patients receiving intravenous sedation plus local anesthesia and in 6 percent (8/127) of patients receiving regional anesthesia. Two of 260 patients (0.8 percent) receiving intravenous sedation plus local anesthesia in the prone position were rolled supine before completing the surgical procedure. Recovery time before discharge for patients treated on an ambulatory basis was significantly shorter for those patients undergoing intravenous sedation plus local anesthesia (79 +/- 34 minutes, n = 174) than for patients undergoing regional anesthesia (161 +/- 63 minutes, n = 45; P < 0.001, t-test). CONCLUSION: Intravenous sedation plus local anesthesia in the prone position is safe and effective for anorectal surgery and offers potential cost savings by decreasing recovery room time for outpatient procedures.     

Percutaneous release for trigger thumb in children under general and local anesthesia

A retrospective trial of percutaneous release for 40 trigger thumbs in 33 children under different types of anesthesia (general versus local) at a mean age of 2.5 years was conducted between February 1989 and March 2003. Based on the tolerance of the child and parents, 20 children were processed using local anesthesia at our office and 13 children were given general anesthesia. We recommend special manipulation to ensure complete release of the A1 pulley when general anesthesia is necessary. Of the 26 trigger thumbs in the local anesthesia group, 23 were successfully released. Only one patient in the general anesthesia group had an unsatisfactory outcome. Percutaneous surgery achieved a 90% successful release rate for trigger thumb in children, without recurrence. There was no statistical difference in the release of trigger thumbs with these two anesthetic procedures (p = 0.66). Overall, 37 trigger thumbs achieved full extension and flexion without any residual deformity following percutaneous release. Our results suggest that percutaneous release for trigger thumb is satisfactory, no matter which method of anesthesia is used.     

Controlled comparison of topical anesthetic agents in flexible upper gastrointestinal endoscopy

Topical anesthetics are generally part of the premedication associated with upper gastrointestinal endoscopy. Selection is not usually based on objective criteria. We performed a randomized study comparing six anesthetic agents: three sprays (Cetacaine, Hurricaine, and 10% Xylocaine spray) and three gargles (2% lidocaine, and two combinations of 2% lidocaine diluted 1:1 with mouthwash). Normal subjects, experienced in undergoing gastroscopy, underwent repeated upper gastrointestinal endoscopic examinations with a 34 F Pentax fiberscope. Topical anesthetic was the only premedication used. The parameters evaluated by the subjects were taste, effectiveness of anesthesia, and ease of scope passage. At the end of the trial each subject ranked the agents in order of preference. Although subjects differed in their preference for the different anesthetic agents (sometimes significantly), there was no single parameter such as taste, degree of anesthesia, or ease of passage of the endoscope that could be correlated with overall preference. All agents gave acceptable levels of local anesthesia, although there was a distinct subjective preference for spray forms. We recommend that if a local anesthetic is used, it should be one of the spray formulations. This recommendation is based on safety, the relative ease of application, and the lack of profound differences between agents.     

Sedation during colonoscopy

In order to perform a proper screening for colonic cancer, repeated colonoscopies are required. Comfort during colonoscopy is very important, so that the patient will accept repeated procedures. Currently, there are 3 types of sedation used during colonoscopy: general anesthesia performed by an anesthesiologist; sedo-analgesia performed by an anesthesiologist or by a gastroenterologist; sedo-analgesia performed by a trained nurse. Sedo-analgesia is the most frequently used type of sedation during colonoscopy worldwide. It is realized by combining midazolam with propofol and/or fentanyl (alfentanyl) or pethidine. According to the data obtained from 34 centers performing colonoscopy in Romania, in 2003, 22,162 colonoscopies were performed: 54.5% without anesthesia, 39.5% with sedation with midazolam and 6% with sedo-analgesia. In a study performed in our department we noticed a significant improvement in the outcome of the colonoscopy when sedo-analgesia was used on a regular basis. The percentage of total colonoscopies (excluding those that could not be continued due to stenosis) was 84.2% when sedation was seldomly performed and 92.3% when sedo-analgesia was regularly used (p=0.042). We believe that the strategy of sedation during colonoscopy in Romania should be changed so that all the patients should benefit from sedo-analgesia, proved to be safe and cost/efficient.     

Anesthesia and Intensive care implications for pituitary surgery: Recent trends and advancements

The advancements in neuro-endocrine surgical interventions have been well supported by similar advancements in anesthesiology and intensive care. Surgery of the pituitary tumor poses unique challenges to the anesthesiologists and the intensivists as it involves the principles and practices of both endocrine and neurosurgical management. A multidisciplinary approach involving the endocrine surgeon, neurosurgeon, anesthesiologist, endocrinologist and intensivist is mandatory for a successful surgical outcome. The focus of pre-anesthetic checkup is mainly directed at the endocrinological manifestations of pituitary hypo or hyper-secretion as it secretes a variety of essential hormones, and also any pathological state that can cause imbalance of pituitary secretions. The pathophysiological aspects associated with pituitary tumors mandate a thorough airway, cardiovascular, neurologic and endocrinological assessment. A meticulous preoperative preparation and definite plans for the intra-operative period are the important clinical components of the anesthetic strategy. Various anesthetic modalities and drugs can be useful to provide a smooth intra-operative period by countering any complication and thus providing an uneventful recovery period.     

Eye surgery in the elderly

The overall risk of eye surgery is quite low, and surgery can generally be performed in all but the sickest patients. Ambulatory eye surgery is now the rule rather than the exception and is generally well tolerated under local anesthesia. It is important for the consultant to remember those conditions that will increase morbidity and appropriately inform the ophthalmologist and anesthesiologist.     

Transfemoral endografting of thoracic aortic aneurysm under local anesthesia: a simple, safe and fast track procedure.

BACKGROUND: Endovascular aneurysm grafting of the descending thoracic aorta is a minimally invasive catheter technique, which is performed under general anesthesia. We describe a technique allowing to perform transfemoral endovascular repair of thoracic aortic repair under local anesthesia. PATIENTS AND METHODS: In 9 consecutive patients local anesthesia was performed in order to gain an opened femoral artery access for the delivery system, and a percutaneous access to the left brachial artery. A pigtail catheter was then placed through the left brachial artery for the location of the origin of the left subclavian artery and/or the aneurysm and self-expanding endoprosthesis was released under fluoroscopic guidance. For the deployment of the endograft a short period of controlled hypotension with nitroglycerin bolus application was produced. RESULTS: All the aneurysms could be successfully sealed with the intended endovascular technique. There was no vascular access complication or pulmonary or ischemic (cardiac, cerebral or peripheral) complication. In the follow-up period of 6 +/- 3 months one patient needed a redo endovascular procedure because of the development of a severe and symptomatic distal endoleak 6 weeks postoperative. This procedure was again performed under local anesthesia. CONCLUSIONS: From a technical point of view, transfemoral endovascular repair of thoracic aneurysm can be performed under local anesthesia. This is a very simple and fast track procedure which combines a minimally invasive catheter technique and a less invasive anesthetic management.     

Effect of the Centers for Medicare & Medicaid Services policy about deep sedation on use of propofol

On 11 December 2009, the Centers for Medicare & Medicaid Services issued a policy stating that deep sedation can only be administered by an anesthesiologist, a certified registered nurse anesthetist, or a trained medical doctor or a doctor of osteopathy not involved in the performance of a medical procedure. Propofol is a popular sedation agent that is usually administered by anesthesia specialists in a service termed monitored anesthesia care (MAC). Monitored anesthesia care adds substantial new fees to procedural sedation. However, available evidence shows that propofol can be used safely by non-anesthesiologists for procedural sedation. The American Society of Anesthesiologists considers that propofol implies deep sedation and should only be administered by anesthesia specialists. The Centers for Medicare & Medicaid Services policy on deep sedation can be viewed as supporting an ongoing conversion to MAC to deliver propofol for procedural sedation. However, the absence of an evidence base supporting a need for MAC to deliver propofol, combined with its high cost, suggests that alternatives to MAC to deliver propofol deserve fair and balanced evaluation.