How are hepatic risk factors assessed during dermatologic preoperative evaluation and management?

Updated: Mar 16, 2020
  • Author: Robert A Schwartz, MD, MPH; Chief Editor: Dirk M Elston, MD  more...
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Answer

In patients with cirrhosis, the preoperative period should focus on nutrition and avoidance of hepatotoxins. The risk of operation is directly correlated with the Child classification of the patient. Hepatic function can be improved by nutritional support and the reduction of ascites and encephalopathy. Factors that preclude all but life-saving operations include Child class C, bacterial contamination, bilirubinemia levels greater than 3 mg/dL, albumin levels less than 3 mg/dL, and malnutrition. Alcoholic hepatitis should be allowed to clear before elective procedures are undertaken. The process of hepatic stabilization may take several weeks past the risk period of delirium tremens following alcohol withdrawal. Hepatic function is best assessed by the clinical status, the return of transaminase levels to baseline, and/or a repeat biopsy of the liver.

A natural decline in hepatic function occurs with age, which is important with respect to drug metabolism. The amide class of anesthetics (eg, lidocaine, prilocaine, mepivacaine, bupivacaine, etidocaine) is primarily metabolized by the liver. The ester-linked local anesthetics (eg, procaine, tetracaine) are mainly metabolized by a plasma cholinesterase and can be used safely in an elderly patient with impaired liver function. Most sedative agents are also metabolized by the liver. A good rule of thumb is to use a reduced dosage of these agents in patients with reduced hepatic function.


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