الفهرس 
INTRODUCTIONOnly 14 pages are availabe for public view
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Abstract
Summary and Conclusion
Hepatic cirrhosis in trauma patients, regardless of severity of injury or the
need for an abdominal intervention, is a poor prognostic indicator. The necessity
of an abdominal operative intervention further amplifies this effect. Trauma and
cirrhosis is, in fact, a deadly duo.
Trauma, in combination with cirrhosis in patients, brings about a unique
challenge. Surgeons in trauma centers treat a variety of patients every day, but
treatment of traumatized cirrhotic patients remains a challenge.
It has been shown that the mortality and morbidity rates increase in
patients with cirrhosis undergoing elective or emergency surgery. Also the
degree of hepatic insuffi ciency is a prime factor for determining the outcome in
these patients.
Adequate hepatic function is necessary in physiological response to
surgery or traumatic injury. The liver plays a vital role in protein synthesis,
detoxifi cation, and immune responses. In a patient subjected to surgical
intervention for traumatic injury, any degree of hepatic insufficiency would
diminish the liver’s ability to carry out these vital metabolic functions.
Because of impaired cirrhotic reserves, a surgical or trauma cirrhotic
patient would be at a great risk of developing complications and death may
occur during the recovery period.
The lower survival and increased complication rates of cirrhotic trauma
patients suggest that there is no “margin for error” in managing these patients.
Thus, several management suggestions can be proposed for the improvement in
cirrhotic patients with abdominal trauma.
It is critical to promptly diagnose and treat injuries in cirrhotic trauma
patients. Since bleeding complications are frequent in cirrhotic patients, early
and aggressive correction of coagulation parameters and hypothermia is crucial.
Liver cirrhotic patients undergoing either elective or emergency surgical
procedure should be managed by the surgeon, anesthesist, and hepatologist for
preoperative evaluation and care before, during, and after surgery.
Management should also be directed toward avoidance of any of the
sinister triad of hypothermia, coagulopathy, and acidosis, which are associated
with significantly increased mortality.
Avoidance of coagulopathy and acidosis depends on initial good
resuscitation and prompt decision making in the next phases. The next
management phase depends largely on the response to resuscitation and the
stability of the patient.
The choice of replacement fluid depends, in part, upon the type of fluid
that has been lost. Blood is indicated in patients who have lost blood and the
main purpose of blood transfusion is to restore oxygen-carrying capacity.
However, the restoration of circulating volume with any fluid is more critical
and urgent than the restoration of oxygen carrying capacity .
The fluid challenge is a method of safely restoring circulating volume
according to physiological need of the body. Fluid is given in small aliquots to
produce a known increment in circulating volume with assessment of the
dynamic haemodynamic response to each aliquot.
The response of CVP should be monitored during a fluid challenge. The
basis of the fluid challenge is to achieve a known increase in intravascular
volume by rapid infusion of a bolus of colloid fluid.
Colloid rather than crystalloid should be used because rapid extravasation
of crystalloid to the interstitial space makes it impossible to know that we have
achieved a defined increment in intravascular volume that lasts long enough for
measurements to be made.
It is important to assess the clinical response and adequacy of tissue
perfusion in addition; if either are inadequate, it is appropriate to monitor cvp
before further fluid challenges or considering further circulatory support
Coagulopathy and thrombocytopenia should be corrected with
replenishment of vitamin K, administration of fresh-frozen plasma (FFP), and
possibly cryoprecipitate transfusion are recommended to reduce a prothrombin
time within normal time and to achieve a goal of platelet counts of >
50,000/mm3.
Fresh frozen plasma and other coagulation factors are indicated in
patients with severe coagulopathy but these fluids should not be used for volume
replacement.
The main progress in reducing perioperative blood loss has been made
through improved surgical and anesthetic techniques and through better
understanding of hemostatic disorders in patients who have liver disease.
Liver dysfunction may result in prolonged duration of action of anesthetic
and neuromuscular blocking agents because of altered metabolism or clearance
rates
Isoflurane is the preferred anesthetic agent for patients with cirrhosis,
while halothane should be avoided if possible. In addition, the actions of
neuromuscular blocking agents may be prolonged due to increased biliary
excretion and decreased pseudocholinesterase activity. Therefore, atracurium is
the drug of choice in patients with liver disease or biliary obstruction, and
doxacurium is recommended for prolonged surgeries. Oxazepam and lorazepam
are the most suitable anxiolytic sedatives, whereas fentanyl and sufentanyl
should be the first-line narcotics.
Poor nutrition is common in these patients and low albumin is different in
survivors and non survivors. Therefore, early appropriate nutritional support
should be provided.
Solutions rich in branched-chain amino acids and low in aromatic amino
acids can reduce hepatic encephalopathy and improve the outcome.
In patients with cirrhosis, liver failure is the most common cause of
postoperative death. Hepatocellular injury is most commonly due to the effects
of anesthesia, intraoperative hypotension, sepsis, or viral hepatitis. A low
threshold is generally maintained for postoperative transfer to the intensive care
unit (ICU).
Patients must be observed closely for signs of acute hepatic
decompensation, such as worsening jaundice, encephalopathy, and ascites.
Sedatives and pain medications should be carefully titrated to prevent an
exacerbation of hepatic encephalopathy. Renal function should also be
monitored because of the risk of hepatorenal syndrome and fluid shifts that
occur due to surgery. These patients should also be monitored for surgical site
complications such as infections, bleeding, and dehiscence. Early enteral feeding
has been suggested to improve outcomes.