Perioperative management of liver disease
From IDWiki
Risk Assessment
- Perioperative mortality increases with MELD score and Child-Pugh class
- Mortality has improved over the years, though
- Mortality increases linearly and continuously with MELD score
- MELD score <8: 6% mortality
- MELD score >20: 50% mortality
- Child-Pugh class
- Old data suggested mortalities of 10%, 30%, and 80% for classes A, B, and C
- Newer data suggests mortalities may have decreased to 10%, 20%, and 60%
Recommended Cutoffs
| Procedure | Recommended cutoffs |
|---|---|
| All surgeries | Surgery generally contraindicated in Child-Pugh C and MELD >20; risk is proportional to MELD |
| CABG | MELD <13.5 |
| Bariatric surgery | Child-Pugh A |
| Lung cancer | Child-Pugh A |
| Colon resection | MELD <9 |
| Lumbar spine surgery | Child-Turcotte-Pugh <6 |
| Head-and-neck cancer surgery | Child-Pugh A, MELD <10 |
Management
- Transfuse platelets to target >50
- No role for fresh frozen plasma (FFP), though it is often done
- No role for prothrombin complex concentrate (Octaplex)
- Ignore the INR
Further Reading
- Northup PG and Caldwell SH. Coagulation in liver disease: a guide for the clinician. Clin Gastroenterol Hepatol. 2013;11(9):1064-74.
- Northup PG, Friedman LS, and Kamath PS.AGA Clinical Practice Update on Surgical Risk Assessment and Perioperative Management in Cirrhosis: Expert Review. Clin Gastroenterol Hepatol. 2019;17:595–606.
