Multiple studies have noted a postoperative increase in INR between postoperative day one and five and a corresponding decrease in platelet count and fibrinogen (29-32). This is thought to be due to decreased synthetic function of the remnant liver as well as hemodilution and consumption of clotting factors. Postoperative coagulopathy

peaks 2-5 days post surgery. Prolongation of PT/INR is often self-limited and usually resolves without the need for transfusion of fresh frozen plasma (FFP) in non-cirrhotics. Prophylactic administration of fresh Inhibitors,research,lifescience,medical frozen plasma to avoid postoperative bleeding has been reported by several centers. Martin et al. from Memorial Sloan Kettering cancer center reported their experience with prophylactic FFP transfusions for prothrombin time >16 seconds in patients undergoing major liver resection for colorectal liver metastases. In this study of 260 patients, 83 patients (32%) received FFP. One patient (0.4%) needed reoperation for postoperative bleeding. There were no major transfusion related Inhibitors,research,lifescience,medical complications (33). Although the incidence of postoperative bleeding is extremely low in Inhibitors,research,lifescience,medical this study, it is

unclear if this is due to the aggressive prophylactic use of FFP or better surgical technique. Other centers have reported prophylactic use of FFP for INR above 2.0. Currently, there is no consensus regarding the criteria for prophylactic FFP transfusion after hepatic

resection. Cirrhotics are at increased risk of bleeding after resection. A combination of FFP transfusions, vitamin K, octreotide and human r FVIIa may be utilized to correct coagulopathy and prevent bleeding. Inhibitors,research,lifescience,medical Pain management Optimal postoperative pain control is necessary for early mobilization and improved respiratory function. Postoperative pain management begins with preoperative planning and formulating a pain management plan that is tailored to an individual patient’s liver function, respiratory and coagulation status, comorbidities, and Rapamycin datasheet extent of resection. Opioids are the mainstay of postoperative Inhibitors,research,lifescience,medical pain control. The most common opioids used are morphine, hydromorphone, and fentanyl. Side effects of opioid administration include sedation, respiratory depression, nausea, vomiting, constipation, hypotension and exacerbation of hepatic encephalopathy. Bay 11-7085 Cirrhotic patients have increased bioavailability of opioids and benzodiazepines due to decreased drug metabolism in the liver resulting in drug accumulation. The size of liver resection has been correlated to the impairment of opioid metabolism, larger volume resections result in greater impairment of opioid metabolism (34). Morphine is poorly excreted in the setting of renal failure. Hydromorphone and fentanyl elimination is less affected by renal impairment (35) and serve as better alternatives in cirrhotic patients with renal dysfunction.