Many patients have a mild degree of encephalopathy, which is of little concern. Severe encephalopathy places patients at risk for aspiration due to depression of protective airway reflexes. In severe liver failure, especially fulminant hepatic failure, patients are at risk for cerebral edema and elevated intra-cranial pressure (ICP). ICP monitoring and treatment may be necessary preopera-
tively to avoid irreversible neurologic injury. Intraoperatively, ICP monitoring should be continued. Arterial pressure must be maintained to provide an adequate cerebral perfusion pressure gradient
Thrombocytopenia is often present in patients with hypersplenism secondary to portal hypertension. This may be worsened by platelet consumption if bleeding has occurred. Fibrinogen concentrations may be low due to decreased synthesis by the diseased liver. Consumption of fibrinogen may occur appropriately during bleeding or inappropriately, if there is fibrinolysis. Other factors may be low due to decreased synthesis and/or increased consumption. It is common for the pro-thrombin time to be significantly elevated.
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