Toward safer sedation in patients with cirrhosis: have we done enough?

摘要

Patients with cirrhosis undergo a variety of diagnostic and therapeutic endoscopic procedures while under conscious sedation, monitored anesthesia care, or, rarely, under general anesthesia. The method of sedation or the selection of the pharmacologic agent is very much dependent on the center and the physician. Currently, there are no specific sedation guidelines for patients with advanced liver disease, despite the fact that most drugs are predominantly cleared by the liver. Liver disease causes significant alterations in liver blood flow, portosystemic shunting, protein synthesis, and drug metabolizing pathways, and these changes could have an impact on the pharmacoki-netics of sedative medications. Increased neurosensitivity to sedative drugs, preexisting subclinical hepatic enceph-alopathy (HE), renal impairment, fluid overload, and previous or ongoing alcohol and drug abuse are additional problems that may have an effect on the level of sedation, recovery time, and potential toxicity.