Pain Management in the Cirrhotic Patient: The Clinical Challenge

Chandok, Natasha; Watt, Kymberly D.

doi:10.4065/mcp.2009.0534

Cited by 239 publications

(253 citation statements)

References 44 publications

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“…28,29 In addition, it is highly bound to serum protein and has unpredictable analgesic effects and an increased risk of toxicity in patients with cirrhosis. 30 Thus, meperidine should be avoided in patients with advanced chronic liver disease or cirrhosis.…”

Section: Opioidsmentioning

confidence: 99%

Role of Supportive Care for Terminal Stage Hepatocellular Carcinoma

Kumar

Panda

2014

Journal of Clinical and Experimental Hepatology

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Section: Opioidsmentioning

confidence: 99%

Role of Supportive Care for Terminal Stage Hepatocellular Carcinoma

Kumar

Panda

2014

Journal of Clinical and Experimental Hepatology

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“…Although the uptake and onset of anesthetic drug action is unaffected, hepatic clearance is dependent upon volume of distribution, functional hepatic blood flow (HBF), hepatic extraction ratio, hepatic microsomal and cytochrome-P450 enzyme activity, decreased plasma-binding proteins (PBP), and decreased biliary excretion (Table 3) [63, [140][141][142][143][144][145][146][147]. In general, short to intermediate halflive drugs at lower doses with longer dose intervals should be used [140,141].…”

Section: Anesthesia Considerationsmentioning

confidence: 99%

“…Care should be taken with benzodiazepines and paralytics, due to a reduction in both CYP-3A4 metabolism and PBP resulting in prolonged duration [1,[140][141][142]144,147,150,151], whereas atracurium, lorazepam, oxazepam, and temazepam undergo non-hepatic conjugation [140,152]. Opioids in LC have significantly reduced metabolism [141,147,153] and prolonged half-lives, potentially exaggerating sedative and respiratory depressant effects, in contrast to fentanyl [1,141,147]. Tricyclic antidepressants, pregabalin, and gabapentin do not require hepatic metabolism and are successful in neuropathic pain management [141].…”

Section: Anesthesia Considerationsmentioning

confidence: 99%

Perioperative Risk Assessment and Management of Cirrhotic Patients

AL¹,

Dong²,

Nayi³

2015

J Hepatol Gastroint Dis

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Liver cirrhosis is an important risk factor for morbidity and mortality in any type of surgical procedure. For these patients, a distinct and tailored patient optimization approach prior to surgery is required in order to best risk mitigate towards avoiding decompensation and related complications, especially with the chronicity of this disease. This review is to enhance understanding of surgical risks in these patients in selecting patients for elective surgery, or managing those following emergency surgery.

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“…As such patients on opiates require close observation in particular after major resections, HRS carried out in the presence of cirrhosis or renal impairment. Better alternatives to simple morphine in cirrhotics include hydromorphone and fentanyl as they are less affected by renal impairment, and are better secreted by the kidney [69] . Intramuscular routes should be avoided, as bioavailability is variable.…”

Section: Hepatic Failurementioning

confidence: 99%

“…Intramuscular routes should be avoided, as bioavailability is variable. Non-steroidal anti-inflammatory agents are generally avoided post hepatectomy due to concerns in relation to coagulation and renal impairment [69] .…”

Section: Hepatic Failurementioning

confidence: 99%

Operative terminology and post-operative management approaches applied to hepatic surgery: Trainee perspectives

Farid

Prasad²,

Morris‐Stiff³

2013

WJGS

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Outcomes in hepatic resectional surgery (HRS) have improved as a result of advances in the understanding of hepatic anatomy, improved surgical techniques, and enhanced peri-operative management. Patients are generally cared for in specialist higher-level ward settings with multidisciplinary input during the initial post-operative period, however, greater acceptance and understanding of HRS has meant that care is transferred, usually after 24-48 h, to a standard ward environment. Surgical trainees will be presented with such patients either electively as part of a hepatobiliary firm or whilst covering the service on-call, and it is therefore important to acknowledge the key points in managing HRS patients. Understanding the applied anatomy of the liver is the key to determining the extent of resection to be undertaken. Increasingly, enhanced patient pathways exist in the post-operative setting requiring focus on the delivery of high quality analgesia, careful fluid balance, nutrition and thromboprophlaxis. Complications can occur including liver, renal and respiratory failure, hemorrhage, and sepsis, all of which require prompt recognition and management. We provide an overview of the relevant terminology applied to hepatic surgery, an approach to the post-operative management, and an aid to developing an awareness of complications so as to facilitate better confidence in this complex subgroup of general surgical patients. Core tip: Applied anatomy as used in hepatic surgery is different to the traditional morphological teaching. Applied hepatic anatomy is complex but trainees require an understanding of the basic principles to allow an appreciation of the operations performed. Complications require a low threshold of suspicion as they often have important consequences in relation to patient outcome. Recognition of such with rapid alerting of senior staff can facilitate timely and effective management. To date, no universal protocol exists for management of the post-operative period and varies from centre to centre. We provide a practical overview of the terminology, post-operative management, and complications associated with hepatic surgery.

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Pain Management in the Cirrhotic Patient: The Clinical Challenge

Cited by 239 publications

References 44 publications

Role of Supportive Care for Terminal Stage Hepatocellular Carcinoma

Role of Supportive Care for Terminal Stage Hepatocellular Carcinoma

Perioperative Risk Assessment and Management of Cirrhotic Patients

Operative terminology and post-operative management approaches applied to hepatic surgery: Trainee perspectives

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