KEY POINTS

1. All volatile anesthetics decrease hepatic blood flow, but desflurane and sevoflurane have the least significant effect on total hepatic blood flow and hepatic oxygen delivery, whereas halothane induces the most profound reductions in hepatic blood flow.
2. Advanced liver disease may impair the elimination, prolong the half-life, and potentiate the clinical effects of several drugs, including morphine, meperidine, alfentanil, vecuronium, rocuronium, mivacurium, benzodiazepines, and dexmedetomidine. These drugs should be used cautiously in patients with cirrhosis or end-stage liver disease from any cause and their dosage and administration adjusted accordingly.
3. Abnormal liver enzyme test results may be seen in up to 4% of normal individuals and up to 36% of psychiatric patients, although the prevalence of clinically significant hepatic dysfunction in these individuals is less than 1%, thus suggesting that further costly preoperative testing is unnecessary in asymptomatic patients.
4. Patients with asymptomatic elevations in serum transaminase levels (less than two times normal values) may undergo surgery with minimal impact on perioperative outcome.
5. Retrospective data suggest that patients with acute hepatitis from any cause are at increased risk for hepatic failure and death after elective surgery. Thus, elective surgery should be delayed in these individuals until resolution of acute hepatocellular dysfunction can be confirmed.
6. Asymptomatic patients with any form of chronic hepatitis should be carefully assessed before elective surgery and meticulous care taken to maintain hepatic perfusion in the perioperative period and avoid any hepatotoxic drugs or significant hypotension that might precipitate liver failure or hepatic encephalopathy.
7. Based on large retrospective studies, patients with cirrhosis who are undergoing abdominal surgery, especially those in Child-Pugh class C, appear to have an increased risk of perioperative death. Elective surgery in these individuals should be avoided, if possible, in favor of less invasive procedures.
8. Postoperative jaundice may occur as a result of intraoperative hepatobiliary injury, anesthetic-induced hepatotoxicity, severe hepatic hypoperfusion (e.g., cardiogenic or hypovolemic shock), and a variety of medications.
9. Patients with the most advanced forms of liver disease (e.g., Child-Pugh class B or C cirrhosis)

   ---

   2225

   should receive management designed to maximize hepatic perfusion and hepatic oxygen delivery and to prevent and treat the complications of hepatic encephalopathy, cerebral edema, coagulopathy, hemorrhage, and portal hypertension.