Sirinek et al identified risk factors for serious complications associated with major abdominal operations in patients with cirrhosis. A perioperative protocol can significantly reduce morbidity and mortality in these patients. The authors are from the Audie Murphy Memorial Veterans Hospital and University of Texas Health Sciences Center in San Antonio.


Risk factors for serious complications:

(1) emergency surgery

(2) coagulopathy (both PT and aPTT each > 2 seconds beyond the upper normal limit for the control)

(3) blood loss > 4 units (900 - 1,000 mL)

(4) exploration of the common bile duct


Preoperative management:

(1) diet restricted in salt, protein and water (2 grams sodium, 20 grams protein, 1500 mL water)

(2) correction of coagulation defects with vitamin K and fresh frozen plasma (FFP)

(3) control of ascites with spironolactone and hydrochlorothiazide, with addition of furosemide if resistant

(4) control of encephalopathy with lactulose and neomycin sulfate


Operative management:

(1) antibiotic prophylaxis given immediately before surgery (using a cephalosporin if tolerated)

(2) meticulous hemostasis to minimize blood loss, with minimal blood transfusion

(3) vasopressin infusion before and during surgery (at 60 units per hour), which is stopped just before closure to identify any bleeding sites

(4) irrigation of abdominal cavity at the end of surgery with a solution containing an antibiotic

(5) postoperative antibiotic prophylaxis continued for 24 hours after surgery



• I added prevention of hypothermia to the spreadsheet. This was not in the original protocol. This is discussed as a risk factor in cirrhotic patients operated on for trauma.

• The protocol included placement of a Swan Ganz catheter, but currently there has been some concern about placing these as often as in the past.


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