Open right hepatectomy for hepatocellular carcinoma in a patient with cirrhosis
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The stem
A 62-year-old man, 84 kg and 176 cm, is scheduled for an open right hepatectomy for a 6 cm hepatocellular carcinoma in segments 5 to 8. He has cirrhosis from hepatitis C, cured with antiviral therapy three years ago, and has never had ascites, encephalopathy or variceal bleeding; surveillance endoscopy showed small varices. Portal vein embolization six weeks ago grew his future liver remnant to 38% of total liver volume. The surgeon plans intermittent inflow occlusion with a Pringle maneuver and asks for a low central venous pressure during transection, and for an epidural.
He has type 2 diabetes and hypertension, and walks two miles a day without symptoms. He drinks no alcohol.
Medications: propranolol 20 mg twice daily, metformin 1000 mg twice daily, lisinopril 10 mg daily.
Allergies: none known.
- Blood pressure 132/78 mmHg, heart rate 62, SpO2 97% on room air, temperature 36.6 °C, BMI 27
- Airway: Mallampati 2, full dentition
- Hemoglobin 13.4 g/dL; platelets 104,000/µL; INR 1.2; fibrinogen 260 mg/dL
- Bilirubin 1.1 mg/dL; albumin 3.6 g/dL; AST 48, ALT 41 U/L
- Sodium 136, potassium 4.2 mEq/L; creatinine 0.9 mg/dL; glucose 142 mg/dL
- Child-Pugh class A (score 5); MELD 9
- ECG: sinus rhythm 62; transthoracic echo: normal ventricular function, estimated RV systolic pressure 28 mmHg, negative bubble study