Hepatic failure and liver transplant anaesthesia

Meet the patient

A 54-year-old man with alcohol-related cirrhosis, MELD 22, comes for an emergency laparotomy with peritonitis. His INR is 2.1 and he is not actively bleeding. The registrar wants to correct the INR with fresh-frozen plasma before induction — the recurring trainee move this topic exists to correct.[1]

Three questions decide every hepatic stem: is this acute liver failure or cirrhosis?, does this INR actually predict bleeding? (no — not alone), and which transplant-phase storm must I pre-empt? Hold those three and the long case and the transplant viva both fall into place.[1]

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1. [1]Kamath PS, Wiesner RH, Malinchoc M, et al. A model to predict survival in patients with end-stage liver disease Hepatology, 2001.PMID 11172350
2. [2]Spahn DR, Bouillon B, Cerny V, et al. The European guideline on management of major bleeding and coagulopathy following trauma: fifth edition Crit Care, 2019.PMID 30917843
3. [3]Mazer CD, Whitlock RP, Fergusson DA, et al. Restrictive or Liberal Red-Cell Transfusion for Cardiac Surgery N Engl J Med, 2017.PMID 29130845
4. [4]Holcomb JB, Tilley BC, Baraniuk S, et al. Transfusion of plasma, platelets, and red blood cells in a 1:1:1 vs a 1:1:2 ratio and mortality in patients with severe trauma: the PROPPR randomized clinical trial JAMA, 2015.PMID 25647203