Nakazawa Keisuke, Ishikawa Risyun, Suzuki Takahiro
Anesthesiology, Nihon University School of Medicine, Tokyo, JPN.
Cureus. 2025 Mar 11;17(3):e80433. doi: 10.7759/cureus.80433. eCollection 2025 Mar.
Patients with severe liver dysfunction present significant perioperative challenges, including the risk of postoperative cognitive dysfunction (POCD) and hepatic encephalopathy (HE), after general anesthesia. While avoiding general anesthesia and deep sedation is crucial for early recovery in this patient population, neuraxial block techniques are often contraindicated due to coagulation disorders. A 73-year-old male patient (190 cm tall, weighing 77 kg) with Child-Pugh C cirrhosis (score 10), coagulopathy (platelets 90,000/μL, prothrombin time (PT) activity 47%), and complex medical history, including treated hepatocellular carcinoma, renal cancer, and bladder cancer, underwent necrotic umbilical hernia repair. The patient, classified as American Society of Anesthesiologists (ASA) physical status IV with a Model for End-Stage Liver Disease (MELD) score of 19, had been hospitalized for two months due to an umbilical hernia infection refractory to antibiotic therapy. After careful preoperative assessment, we selected monitored anesthesia care (MAC) as the preferred anesthetic approach due to the patient's high surgical risk. We performed a bilateral rectus sheath block (RSB) using diluted ropivacaine (0.15%, total 80 mL) with epinephrine (15 μg). Sedation was achieved using dexmedetomidine without a loading dose, supplemented with midazolam and low-dose remifentanil. This approach allowed us to maintain spontaneous breathing while providing adequate analgesia and patient comfort. The surgery was completed successfully with stable hemodynamics and respiratory functions. Throughout the procedure, hemodynamic parameters remained within 20% of baseline values, and bispectral index (BIS) values were maintained between 65 and 80, indicating appropriate sedation depth without excessive anesthetic administration. Ultrasound-guided RSB combined with carefully titrated MAC provides safe and effective anesthesia for umbilical hernia repair in patients with severe liver dysfunction. This approach maintains spontaneous breathing, delivers effective analgesia for somatic and visceral pain, and facilitates clearer differentiation between residual anesthetic effects and worsening HE postoperatively. When coagulopathy precludes neuraxial techniques, this pharmacokinetically informed strategy offers a valuable alternative for high-risk abdominal wall procedures.
严重肝功能不全的患者在全身麻醉后会面临重大的围手术期挑战，包括术后认知功能障碍（POCD）和肝性脑病（HE）的风险。虽然避免全身麻醉和深度镇静对于这类患者的早期恢复至关重要，但由于凝血功能障碍，神经阻滞技术往往被列为禁忌。一名73岁男性患者（身高190cm，体重77kg），患有Child-Pugh C级肝硬化（评分10）、凝血功能障碍（血小板90,000/μL，凝血酶原时间（PT）活性47%），并有复杂的病史，包括曾接受治疗的肝细胞癌、肾癌和膀胱癌，接受了坏死性脐疝修补术。该患者被归类为美国麻醉医师协会（ASA）身体状况IV级，终末期肝病模型（MELD）评分为19，因脐疝感染对抗生素治疗无效已住院两个月。经过仔细的术前评估，由于患者手术风险高，我们选择监测麻醉管理（MAC）作为首选的麻醉方法。我们使用稀释的罗哌卡因（0.15%，总量80mL）加肾上腺素（15μg）进行双侧腹直肌鞘阻滞（RSB）。使用右美托咪定不用负荷剂量来实现镇静，并辅以咪达唑仑和低剂量瑞芬太尼。这种方法使我们能够在提供充分镇痛和患者舒适度的同时维持自主呼吸。手术成功完成，血流动力学和呼吸功能稳定。在整个手术过程中，血流动力学参数保持在基线值的20%以内，脑电双频指数（BIS）值维持在65至80之间，表明镇静深度合适，没有过度使用麻醉剂。超声引导下的RSB联合仔细滴定的MAC为严重肝功能不全患者的脐疝修补术提供了安全有效的麻醉。这种方法维持自主呼吸，为躯体和内脏疼痛提供有效的镇痛，并有助于更清楚地区分残留麻醉效果和术后HE病情恶化。当凝血功能障碍排除神经阻滞技术时，这种基于药代动力学的策略为高风险腹壁手术提供了一种有价值的替代方法。
