الفهرس 
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Abstract
Liver cirrhosis is the tenth leading cause of death[1]. Although cirrhosis-related deaths have decreased over the years, the impact of cirrhosis remains with approximately [2]. Cirrhotic patients often suffer from complications Cirrhosis impairs nutrition, alters response to stress, and affects the functions of other organ systems.[3]
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[4].
It has been shown that the mortality and morbidity rates increase in patients with cirrhosis undergoing elective or emergency surgery[5]. Also the degree of hepatic insuffi ciency is a prime factor for determining the outcome
in these patients[6]
Adequate hepatic function is necessary in physiological response to surgery or traumatic injury[7]. 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[8]. 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[9].
Liver insufficiency was positively associated with a poorer outcome. 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[10]. 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[11]. 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[12,13]
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.[16]
It has been shown that converting Child C patient to Child B preoperatively improved survival after surgery.13 Hence, proper perioperative evaluation and management which addressed the common features of advanced liver disease may decrease the risk of complications or death following surgery. Before surgery, particularly attention should be paid to the management of coagulation status, renal function, fluid and electrolite, malnutrition, encephalopaty and ascites[14-17]
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 3 seconds of normal time and to achieve a goal of platelet counts of > 50,000/mm3.[18]
Bleeding in major surgical procedures involving the liverAlthough blood loss in patients undergoing liver surgery has decreased substantially during the last decade, excessive blood loss can still be a major concern in individual patients. Bleeding problems are not limited to surgical patients who have a cirrhotic liver; they may also occur in patients who have a normal liver. Extensive bleeding may require the transfusion of blood or blood products, which are associated with increased rates of morbidity and mortality. [19-24]
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.[25,26]
Refinements in surgical techniques and better understanding of the liver anatomy have provided important contributions to the reduction of blood loss during liver surgery. In recent years, several new techniques have been developed to perform more complex surgical interventions in patients who have a pre-existing bleeding risk, such as patients who have liver cirrhosis.[27,28]
Transfusion of blood products may be required in the case of active and serious bleeding, Although excessive bleeding may, and should, be managed by the transfusion of blood products, such as FFP, platelet concentrates, and packed red blood cells (RBC),[29] it is also becoming clear that no consensus currently exists on transfusion practice in liver surgery. Prospective, multicenter studies with predetermined hemostasis assessment and transfusion guidelines are needed and would improve our understanding of the correction and prevention of massive bleeding during liver surgery, with likely improvements in patient outcomes.
In addition to monitoring and correcting blood loss and associated metabolic abnormalities, anesthesiologists play a key role in reducing blood loss during liver surgery by maintaining a low CVP.[30]
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 methoxyflurane, chloroform and 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. In contrast, morphine, meperidine and barbiturates can precipitate hepatic encephalopathy and should be avoided[31] the patients with preexistent liver cirrhosis have a significantly higher NOM failure rate (92%) when compared with that (19%) of noncirrhotic patients. The reasons for the high failure rate of NOM in patients with coexistent BSOI and liver cirrhosis have rarely been discussed in the English literature. Spontaneous hemostasis seems to be difficult for these patients.[32]
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.
Serious sequelae of decompensated cirrhosis include severe sepsis and secondary disseminated intravascular coagulation (DIC). These potential complications emphasize the need for maintaining a low threshold for ICU-level monitoring.[ 34].