NMS. Casos Clínicos

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Chapter 1 ♦ Preoperative Care

Table 1-9: Model for End-Stage Liver Disease MELD uses the patient’s values for serum bilirubin, serum creatinine, and the INR for prothrombin time to predict survival. It is calculated according to the following formula: MELD = 3.78(Ln serum bilirubin [mg/dL]) + 11.2(Ln INR) + 9.57(Ln serum creatinine [mg/dL]) + 6.43 UNOS has made the following modifications to the score: • If the patient has been dialyzed twice within the last 7 days, then the value for serum creatinine used should be 4.0. • Any value <1 is given a value of 1 (i.e., if bilirubin is 0.8, a value of 1.0 is used) to prevent the occurrence of scores below 0. (The natural logarithm of 1 is 0, and any value <1 would yield a negative result.) Patients with a diagnosis of liver cancer will be assigned a MELD score based on how advanced the cancer is. In interpreting the MELD score in hospitalized patients, the 3-month mortality is as follows: • ≥40—71.3% mortality • 30–39—52.6% mortality • 20–29—19.6% mortality • 10–19—6.0% mortality • <9—1.9% mortality INR, international normalized ratio; MELD, Model for end-stage liver disease; UNOS, United network for organ sharing. Data from: Singal AK, Kamath PS. Model for end-stage liver disease. J Clin Exp Hepatol . 2013;3(1):50– 60. https://doi.org/10.1016/j.jceh.2012.11.002

The benefits of the surgery must outweigh the risks of the surgery; otherwise, the surgery should not be performed. Q: Would you proceed with the surgery? A: Recall that patients with chronic liver failure can tolerate most surgical procedures well if they are in a relatively compensated state preoperatively . They should abstain from alcohol . If the hernia is repaired but the ascites remains uncontrolled, there is a significant chance of hernia recurrence and bacterial peritonitis. Thus, patients should be medically optimized before repair. Ascites should be controlled with potassium-sparing diuretics, as well as sodium and water restriction. SAMPLE Digging Deep