Veterinary Anesthesia & Analgesia Support Group
Practical Information for the Compassionate Veterinary Practitioner
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  Liver Disease Management Basics
  Bob Stein
  December, 2004


a)      General Approach

i)        Generally speaking, we are referring to symptomatic patients with a significant liver dysfunction

(1)   Higher risk is associated with low albumin, elevated bilirubin, elevated coag tests

(2)   A clinically normal patient with elevated ALT and/or ALP who has normal hepatic function does not necessarily require a unique perianesthetic approach

ii)       Generally, use lower doses of everything

iii)     Avoid agents that require extensive liver metabolism for clearance

iv)     Regardless of agents used, expect a more prolonged anesthetic recovery

b)      Pre-anesthetic Medications

i)        Reversible agents are advantageous

ii)       Benzodiazepines and opioids are generally good choices

(1)   Use lower doses, titrating to effect

(2)   Morphine may be the most attractive opioid as it is the least protein bound opioid

(a)    Morphine’s route of metabolism is the best preserved in liver failure (glucuronidation)

c)      Induction

i)        Propofol

ii)       Etomidate is an attractive agent for severe liver disease cases but caution must be extended to the proplylene glycol containing preparations

(1)   The lipuro version (similar to propofol) is preferred over the propylene glycol containing preparation

d)      Maintenance

i)         Isoflurane or Sevoflurane

e)      Support

i)        Epidural analgesia and regional analgesia help reduce systemic doses of opioids

ii)       IV fluids highly recommended

iii)     May need glucose support

(1)   Monitor blood glucose

(2)   Consider 5% dextrose containing fluids if needed to maintain blood glucose



a)      Pre-anesthetic Medications

i)        Avoid acepromazine

ii)       Avoid alpha-2 agonists (xylazine & medetomidine)

iii)     Avoid high doses of opioids and benzodiazepines

b)      Induction

(1)   Avoid barbiturates, especially if hypoalbuminemic

c)      Maintenance

i)        Avoid halothane

ii)       Avoid methoxyflurane

d)      Support

i)        Avoid hyperventilation and positive pressure ventilation

(1)   Both can decrease hepatic blood flow

(2)   Maintain PaCO2 at or slightly above 40 helps preserve hepatic blood flow

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