Liver disease and general anesthesia: what the anesthesiologist needs to know

The increasing global burden of liver disease leads to more frequent encounters of anesthesiologists with these high-risk patients. This review summarizes current evidence on perioperative management of patients with liver disease, acute liver failure, and acute-on-chronic liver failure undergoing surgery.

The etiology of liver disease is evolving with metabolic dysfunction on the rise creating new perioperative challenges. Patients with liver disease are particularly at risk of cardiovascular events, impaired glucose regulation, and delayed anesthetic recovery. Conventional coagulation assays inadequately reflect bleeding risk in patients with liver disease, whereas viscoelastic-guided coagulation strategies are associated with reduced transfusion requirements. Overall, 90-day mortality is about five-fold higher in patients with liver cirrhosis compared with the general population. Risk scores and clinical assessments are necessary to balance patient- and procedure-related risks during preoperative evaluation.

Patients with liver disease undergoing surgery constitute one of the highest-risk surgical populations. Systematic preoperative assessment, individualized anesthetic drug selection, viscoelastic-guided coagulation management, and early multidisciplinary involvement are essential to improve outcomes. High-quality prospective evidence to guide anesthetic practice in patients with liver disease is urgently needed.