Child-Pugh B cirrhosis for urgent laparoscopic cholecystectomy54-year-old man, 76 kg, for urgent laparoscopic cholecystectomy for acute cholecystitis not settling on antibiotics

The patient

The examiner asks

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1. Consider

   What are your concerns?

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   • A 54-year-old with Child-Pugh B alcohol-related cirrhosis, ascites and varices, for urgent laparoscopic cholecystectomy. Patient
   • Child B carries 12–31% operative mortality; his MELD of 14 means proceed with close monitoring afterwards. Disease
   • His circulation is hyperdynamic: high output, low pressure, low resistance, and a blunted response to pressors.
   • Portal hypertension and varices; his propranolol lowers his bleeding risk.
   • I look for hepatorenal syndrome in his creatinine, and hepatopulmonary syndrome if he desaturates sitting up.
   • Laparoscopy is reasonable in Child B, with less blood loss than open surgery. Surgery

2. Prepare

   How will you prepare him?

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   • Full blood count, clotting, electrolytes and creatinine; viscoelastic testing ready in theatre. Disease
   • His INR of 1.6 overstates his bleeding risk; his clotting system is rebalanced.
   • Any infection treated, and his fluid status, kidneys and ascites optimised.
   • Two large-bore cannulas, arterial line, cross-matched blood; cell salvage only if the field is free of infected bile. Surgery
   • Albumin rather than large crystalloid volumes; cirrhotics may benefit from it. Disease

3. Plan

   How will you anaesthetise him?

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   • Rapid sequence induction; his ascites raises aspiration and hypoxia risk at induction. Airway
   • A reduced induction dose; sedatives last longer in him. Disease
   • RSI with suxamethonium; cisatracurium for maintenance, since neither needs his liver.
   • Sevoflurane barely cuts his liver blood flow; ascites cuts his FRC, so lung-protective ventilation with PEEP.
   • His pressure kept at baseline with vasopressors rather than large fluid loads.
   • No epidural with his platelets of 68; a TAP block or port-site infiltration instead. After surgery

4. Crisis

   As the gallbladder comes off the liver bed, bleeding becomes torrential. BP 72/40, HR 105, Hb 7.0 g/dL. What do you do?

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   • Massive haemorrhage protocol: called now; the surgeon packs or converts to open. Crisis
   • Red cells, plasma and platelets close to 1:1:1, warmed, through large-bore lines.
   • Tranexamic acid: 1 g IV across 10 minutes, then 1 g across 8 hours.
   • Viscoelastic test now; cryoprecipitate if fibrinogen is below 80–100 mg/dL while he bleeds.
   • Platelets if his count falls below 50 × 10⁹/L.
   • Ionised calcium checked often; his liver clears citrate slowly.
   • Salvaged blood returned only if the field is free of infected bile; ICU afterwards. After surgery

5. Crisis

   On day two he is drowsy and confused, with a flapping tremor. What now?

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   • Hepatic encephalopathy until proven otherwise; I first exclude stroke and drug effects. Crisis
   • His likely precipitants: infection, electrolyte or metabolic upset, and sedatives.
   • Benzodiazepines stopped, and opioids pared back.
   • Lactulose and rifaximin to cut his gut ammonia production.
   • Empirical antibiotics if pneumonia or spontaneous bacterial peritonitis is possible.
   • He stays in ICU while his consciousness is falling. After surgery