Anaesthesia in Liver Failure

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Liver failure presents complex perioperative challenges due to impaired synthetic function, coagulopathy, fluid shifts, and multi-organ involvement. Classification: Acute liver failure (ALF—encephalopathy within 8 weeks of symptom onset in patient without pre-existing liver disease), acute-on-chronic liver failure (ACLF—acute decompensation of chronic liver disease), chronic liver disease (compensated or decompensated). Synthetic dysfunction: Reduced albumin (oedema, ascites, altered drug binding), coagulopathy (all clotting factors except VIII reduced—INR most sensitive marker, platelet sequestration in spleen from portal hypertension), reduced pseudocholinesterase (prolonged succinylcholine effect). Metabolic: Hypoglycaemia (reduced gluconeogenesis, hyperinsulinism), lactic acidosis (reduced lactate clearance), drug metabolism impaired (CYP450 activity reduced, prolonged drug effects). Cardiovascular: Hyperdynamic circulation (increased CO, decreased SVR), portal hypertension, varices. Respiratory: Hepatopulmonary syndrome (intrapulmonary shunting, hypoxia), hepatic hydrothorax (pleural effusions from diaphragmatic defects). Renal: Hepatorenal syndrome (functional renal failure, kidneys histologically normal, type 1 acute and severe, type 2 chronic), prerenal azotaemia from diuretics. CNS: Hepatic encephalopathy (ammonia neurotoxicity, astrocyte swelling, GABA-ergic neurotransmission), cerebral oedema (ALF), increased ICP. Anaesthetic implications: High-risk surgery (Child-Pugh C mortality 50-80% for major surgery, MELD >20 high risk); correct coagulopathy pre-op (FFP, platelets, vitamin K 10 mg IV), careful fluid management (avoid overload, avoid hypovolaemia), avoid hepatotoxic drugs (halothane, high-dose paracetamol), reduced drug doses (prolonged duration), neuraxial generally contraindicated (coagulopathy), avoid hypotension (preserve hepatic perfusion), monitor glucose (hypoglycaemia risk). Specific scenarios: TIPSS procedure (reduce portal pressure, local + sedation or GA, monitoring for encephalopathy), liver transplantation (complex multi-phase surgery with massive transfusion requirements, venovenous bypass or piggyback technique, post-reperfusion syndrome), acute liver failure (ICP monitoring if grade 3-4 encephalopathy, cerebral perfusion pressure maintenance, mannitol/hypertonic saline for oedema, urgent transplantation evaluation). Postoperative: ICU admission, continued monitoring for encephalopathy, coagulopathy, renal function, glucose; lactulose and rifaximin for encephalopathy. Indigenous patients: Higher rates of viral hepatitis, alcohol-related liver disease; delayed presentation common; culturally sensitive end-of-life discussions important. [1-10]