[Durgical](https://durgical.com/en/) › [DurgiPedia](https://durgical.com/en/durgipedia/) › [Anaesthesia and ICU](https://durgical.com/en/anaesthesia/) › [By patient and by surgery](https://durgical.com/en/anaesthesia/areas/by-patient/) › The patient with liver disease

# The patient with liver disease

- Patient and surgery

A scarred liver clears drugs slowly, makes fewer clotting proteins and copes badly with low blood pressure, so surgery carries extra risk.

Updated Nov 13, 2026

## Key points

- The Child–Pugh score uses bilirubin, albumin, INR, ascites and encephalopathy; class A carries modest surgical risk, class C a very high one.
- Elective surgery is usually postponed in decompensated cirrhosis or Child–Pugh class C; acute hepatitis and alcoholic hepatitis also argue for delay.
- Keep hepatic blood flow: avoid hypotension, hypoxaemia and high airway pressures, since the cirrhotic liver has little reserve.
- Atracurium and cisatracurium, remifentanil and propofol are convenient; benzodiazepines and long-acting opioids can precipitate encephalopathy.
- A raised INR overstates bleeding risk in cirrhosis; viscoelastic testing and platelet count guide correction better than giving plasma for a number.

On this page

- The basics Key points
- What it is
- What changes in this patient
- Anaesthetic plan (and why)
- The Child–Pugh score: add the points of the five items (class A 5–6, B 7–9, C 10–15)
- Next step
- Memory aid
- Elsewhere in DurgiPedia

- Clinical Risks and complications

- Study Test yourself

- Connections Connections

## What it is

In cirrhosis the liver loses working cells and blood flow is diverted around it, and the changes reach the whole body. The circulation becomes hyperdynamic, with a high cardiac output and a low vascular resistance, so blood pressure falls easily under anaesthesia. Portal hypertension brings varices, ascites and a large spleen with low platelets. The liver makes less albumin and fewer clotting factors, but also fewer natural anticoagulants, so the balance of clotting is fragile: a high INR does not reliably predict bleeding, and clots can still form. Drug handling changes: drugs cleared by the liver last longer, low albumin raises free drug levels, and sedatives can trigger hepatic encephalopathy. The lungs may suffer from ascites splinting the diaphragm, from hepatopulmonary syndrome or from portopulmonary hypertension, and the kidneys from hepatorenal syndrome. Risk is graded with the Child–Pugh score, built from bilirubin, albumin, INR, ascites and encephalopathy, and with the MELD score; surgical mortality rises steeply from class A to class C, and elective surgery is usually avoided in class C. The anaesthetic plan aims to keep hepatic blood flow and oxygen delivery steady, choose drugs whose elimination does not depend on the liver, correct clotting by testing rather than by numbers alone, and watch closely for decompensation.

## What changes in this patient

- Circulation: hyperdynamic state with low systemic vascular resistance, relative hypovolaemia and cirrhotic cardiomyopathy.
- Clotting: low platelets and clotting factors but also low natural anticoagulants: both bleeding and thrombosis can occur.
- Drugs: slower hepatic clearance, low albumin with more free drug, larger volume of distribution, and less plasma cholinesterase.
- Lungs: ascites and pleural effusions reduce lung volumes; hepatopulmonary syndrome causes hypoxaemia; portopulmonary hypertension strains the right heart.
- Brain and kidneys: encephalopathy can be triggered by sedatives, bleeding, infection or constipation; hepatorenal syndrome follows hypovolaemia and hypotension.
- Metabolism: hypoglycaemia, hyponatraemia and malnutrition; ascites and varices raise the risk of aspiration and bleeding.

## Anaesthetic plan (and why)

- Grade severity with Child–Pugh and MELD and look for decompensation — the score predicts risk and decides whether elective surgery should wait.
- Correct what can be corrected first: drain or control ascites, treat infection, encephalopathy and electrolyte problems — each one adds risk.
- Test clotting with platelets, fibrinogen and viscoelastic tests where available, and correct when bleeding or before high-risk steps — INR alone misleads.
- Use rapid-sequence induction when ascites is tense or the patient has recently bled — raised abdominal pressure increases aspiration risk.
- Choose atracurium or cisatracurium, remifentanil or short-acting opioids, and a modern volatile or propofol — they rely little on the liver.
- Keep blood pressure, oxygenation and cardiac output near normal, and avoid excessive airway pressure — the liver depends on its blood flow.
- Pass gastric tubes gently and only when needed in known varices — they can bleed heavily.
- Replace volume with care, using albumin after large-volume ascites drainage, and monitor glucose and sodium — prevents circulatory collapse and swings.
- Plan regional anaesthesia only after checking platelets and clotting — the risk of a neuraxial haematoma is higher.

## The Child–Pugh score: add the points of the five items (class A 5–6, B 7–9, C 10–15)

| Item | 1 point | 2 points | 3 points |
| --- | --- | --- | --- |
| Total bilirubin | Below 34 µmol/L | 34–50 µmol/L | Above 50 µmol/L |
| Albumin | Above 35 grams per litre | 28–35 grams per litre | Below 28 grams per litre |
| INR | Below 1.7 | 1.7–2.3 | Above 2.3 |
| Ascites | None | Mild or controlled with diuretics | Moderate to severe or refractory |
| Hepatic encephalopathy | None | Mild (grade 1–2) | Severe (grade 3–4) |

## Risks and complications

- Hypotension at induction and during surgery from low vascular resistance and relative hypovolaemia.
- Major bleeding from varices, low platelets or surgical raw surfaces; thrombosis in the portal vein or elsewhere.
- Hepatic encephalopathy and prolonged sedation after benzodiazepines, opioids or a gastrointestinal bleed.
- Acute kidney injury and hepatorenal syndrome after hypotension, hypovolaemia, nephrotoxins or large-volume paracentesis without albumin.
- Postoperative decompensation: rising bilirubin, worsening ascites, infection, wound breakdown and liver failure.
- Hypoglycaemia and hyponatraemia; prolonged effect of suxamethonium when plasma cholinesterase is low.

## Next step

- Watch in recovery for encephalopathy, bleeding and hypotension; check glucose, sodium, haemoglobin and clotting after major surgery.
- Call a senior and the hepatology team for new confusion, rising bilirubin or INR, falling urine output or suspected variceal bleeding.
- Prevent encephalopathy: avoid benzodiazepines, treat constipation with lactulose as prescribed, and look for infection early.
- Use paracetamol at a reduced total daily amount agreed with the team, avoid NSAIDs, and keep opioids short-acting and minimal.
- Check creatinine and urine output daily for the first days, since hepatorenal syndrome can develop after surgery.
- Before elective surgery in class B or C, review risk with the patient and the hepatology team and consider a less invasive option.

## Memory aid

ABCDE for Child–Pugh: Albumin, Bilirubin, Clotting (INR), Distension (ascites), Encephalopathy.

## Test yourself

Think of the answer, then tap the question to see it.

## Which five items make up the Child–Pugh score?

Total bilirubin, serum albumin, INR (or prothrombin time), ascites and hepatic encephalopathy. Points are added to give class A, B or C.

## Why is a high INR a poor guide to bleeding risk in cirrhosis?

The liver makes fewer clotting factors and fewer natural anticoagulants, so clotting is rebalanced; the INR measures only one side. Viscoelastic tests and platelets guide better.

## Why are benzodiazepines avoided in patients with cirrhosis?

They are cleared slowly by the diseased liver, have a stronger effect with low albumin, and can precipitate or worsen hepatic encephalopathy.

## Why does blood pressure fall easily at induction in cirrhosis?

Cirrhosis causes a hyperdynamic circulation with low vascular resistance and relative hypovolaemia, so vasodilating anaesthetic drugs drop pressure further.

[Add to my cards (4)](https://durgical.app/estudiar/?add=/en/anaesthesia/the-patient-with-liver-disease/)

## Elsewhere in DurgiPedia

- [Functions of the liver](https://durgical.com/en/physiology/functions-of-the-liver/)
- [Liver tests: hepatocellular or cholestatic?](https://durgical.com/en/clinical-skills/liver-tests-hepatocellular-or-cholestatic/)
- [Coagulation tests: PT/INR, aPTT, fibrinogen and D-dimer](https://durgical.com/en/clinical-skills/coagulation-tests-pt-inr-aptt-fibrinogen-and-d-dimer/)
- [Liver failure: acute, chronic and acute-on-chronic](https://durgical.com/en/general-pathology/liver-failure-acute-chronic-and-acute-on-chronic/)

## Connections

## Related 8

- [The pre-anaesthetic visit: history, examination and tests](https://durgical.com/en/anaesthesia/the-pre-anaesthetic-visit-history-examination-and-tests/)
- [Rapid-sequence induction and intubation](https://durgical.com/en/anaesthesia/rapid-sequence-induction-and-intubation/)
- [Anticoagulants, antiplatelets and neuraxial blocks](https://durgical.com/en/anaesthesia/anticoagulants-antiplatelets-and-neuraxial-blocks/)
- [Massive haemorrhage in theatre](https://durgical.com/en/anaesthesia/massive-haemorrhage-in-theatre/)
- [Intraoperative hypotension](https://durgical.com/en/anaesthesia/intraoperative-hypotension/)
- [Postoperative delirium](https://durgical.com/en/anaesthesia/postoperative-delirium/)
- [Postoperative pain: multimodal analgesia](https://durgical.com/en/anaesthesia/postoperative-pain-multimodal-analgesia/)
- [The patient with kidney disease](https://durgical.com/en/anaesthesia/the-patient-with-kidney-disease/)

## Related conditions 4

- [Cirrhosis](https://durgical.com/en/conditions/cirrhosis/)
- [Portal hypertension](https://durgical.com/en/conditions/portal-hypertension/)
- [Hepatic encephalopathy](https://durgical.com/en/conditions/hepatic-encephalopathy/)
- [Hepatorenal syndrome](https://durgical.com/en/conditions/hepatorenal-syndrome/)

## In Pharmacology 10

- [Atracurium](https://durgical.com/en/pharmacology/atracurium/)
- [Cisatracurium](https://durgical.com/en/pharmacology/cisatracurium/)
- [Remifentanil](https://durgical.com/en/pharmacology/remifentanil/)
- [Propofol](https://durgical.com/en/pharmacology/propofol/)
- [Benzodiazepines](https://durgical.com/en/pharmacology/classes/benzodiazepines/)
- [Suxamethonium](https://durgical.com/en/pharmacology/suxamethonium/)
- [Paracetamol](https://durgical.com/en/pharmacology/paracetamol/)
- [Nonsteroidal anti-inflammatory drugs (NSAIDs)](https://durgical.com/en/pharmacology/classes/nonsteroidal-anti-inflammatory-drugs/)
- [Human albumin](https://durgical.com/en/pharmacology/human-albumin/)
- [Lactulose](https://durgical.com/en/pharmacology/lactulose/)

[← All of anaesthesia](https://durgical.com/en/anaesthesia/)

Educational content; it does not replace supervised training, your institution's protocols or the anaesthetist's or intensivist's decision. It contains no doses and no ventilator or infusion settings.

Sources: [Use Of The Child Pugh Score In Liver Disease](https://www.ncbi.nlm.nih.gov/books/NBK542308/) (StatPearls (NCBI Bookshelf), 2023).

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Source: https://durgical.com/en/anaesthesia/the-patient-with-liver-disease/
License: CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). Cite as: DurgiPedia (durgical.com), https://durgical.com/en/anaesthesia/the-patient-with-liver-disease/