Good points Pro.
In a perfect world every patient would come with a complete history, diagnostic studies and consults, but in the real world you frequently have to use your clinical judgment to compensate for the missing data.
This patient certainly did not have all the data you need but you could still make certain assumptions:
1- She probably did not have a severe hepato-pulmonary syndrome because she did not have severe hypoxia and because she already had a TIPS done which usually improves the hepato-pulmonary syndrome (although the mechanism remains unknown).
2- Cardio-vascular status: We don't have coronary studies but she denies chest pain and although she is sedentary she can still perform her basic functions.
She can still have coronary artery disease but she does not have unstable angina or ongoing ischemia (negative troponin and negative EKG).
She has a broken hip that needs to be fixed regardless of her CAD.
She is hypotensive for the reasons you mentioned and she has many other hormonal and metabolic issues but that does not change the fact that there isn't much you can do to her to fix these issues.
The best thing you can do is fix her hip.
3- Sure she has hepatic encephalopathy but she still needs her hip fixed.
4- Her coagulation can be transitionally fixed for a few hours as you mentioned and that's all we can do to get her to have this surgery without major bleeding.
Patients with end stage liver disease are very challenging and need a vigilant Anesthesiologist to survive surgery and this is where I agree with you, you (as a consultant anesthesiologist) are the most qualified person to take care of this type of patient and give her the best possible care.
In patient with liver failure, even before you think about what paralytic agent or fancy block or reversal of coagulopathy you'll use, you must be aware of the cardiopulmonary implications associated with this disease.
I think we have overlooked the fact that patients with LF can typically have diferent degrees of intrapulmonary shunting and pulmonary hypertension. By the very nature of the disease, they will also have a hyperdynamic cardiac status and increase vasodilatory state as a result of upregulation of nitric oxide synthase. This should be looked up in the context of any other potentially complicating issues such as CAD or such.
It would have been good to know that meds she was on as her confusion could be explained by hepatic encephalopathy. Was she on aldactone? What was her renal function? Her coagulopathy requires no explanation and her thrombocytopenia, although transiently correctable with transfusion, will not improve since her levels of thrombopoietin will be expectedly low.
Having done a fair number of liver transplants I can tell you these issues ought to be examined, if at all possible, as they can become a nightmare scenario for you. This may not be possible in an emergency situation but it's worth keeping in the back of your mind. Check out her MELD scores to have an idea of what you're dealing with.
Just wanted to point that out.
I've always said that giving anesthesia is what the nurses do. Understanding how the pathophysiology of a disease will guide the anesthetic plan is what anesthesiologists do.
