01 January 2025 : Review article
Impact of Liver Disease on Use of Muscle Relaxants in Anesthesia: A Comprehensive Review
Paweł Radkowski
123ABCDEFG, Maciej Szewczyk 4ABCDEFG*, Anna Łęczycka5BEF, Kacper Kowalczyk5BEF, Mariusz Kęska 12BEF, Tomasz Stompór 6DG
DOI: 10.12659/MSM.945822
Med Sci Monit 2025; 31:e945822
Introduction
Liver Function Tests and Assessment of Liver Function
AST and ALT
The De Ritis Ratio
Chronic Liver Disease
Liver Cirrhosis
Steatotic Liver Disease
Acute Liver Failure
Acute-On-Chronic Liver Failure
Characteristic of Succinylcholine
Impact of Hepatic Insufficiency on Succinylcholine Use
Characteristics of Benzylisoquinolones
Atracurium Characteristic and Its Use in Hepatic Insufficiency
Cisatracurium Characteristic and Its Use in Hepatic Insufficiency
Mivacurium Characteristic and Its Use in Hepatic Insufficiency
Aminosteroids Charateristics
Pipecuronium Characteristics and Uses in Liver Insufficiency
Pancuronium Characteristics and Use in Patients with Hepatic Insufficiency
Vecuronium Characteristic and Its Use in Hepatic Insufficiency
Rocuronium Characteristic and Its Use in Hepatic Insufficiency
Neostigmine and Its Use in Hepatic Insufficiency
Sugammadex Characteristic and Its Use in Hepatic Insufficiency
Summary of Neuromuscular Blocking Agents Use in Hepatic Insufficiency and Actual Recommendations
Future Directions
Conclusions
References
Table 5 Summary of the 2023 recommendations from American and European anesthesiology societies regarding the use of skeletal muscle relaxants and neuromuscular blockade reversal agents.
| Recomendations | ||
|---|---|---|
| Strenght of recommendations | ASA | ESAIC |
| Strongly recommended | Not to rely solely on clinical assessment of blockade reversal | Usage a muscle relaxant to facilitate tracheal intubation |
| Choosing quantitative monitoring over qualitative assessment for residual neuromuscular blockade | Usage of muscle relaxants to reduce pharyngeal and/or laryngeal injury following endotracheal intubation | |
| Avoid using ocular muscles for monitoring | Us a fast-acting muscle relaxant for RSII such as succinylcholine 1 mg·kg or rocuronium 0.9 to 1.2 mg·kg | |
| To use the adductor pollicis muscle for neuromuscular monitoring | Deep neuromuscular blockade if surgical conditions need to be improved | |
| To confirm a TOFR ≥0.9 before intubation when using quantitative monitoring | Use of ulnar nerve stimulation and quantitative NMM at the adductor pollicis muscle to exclude residual paralysis | |
| To consider using neostigmine as an alternative to sugammadex in cases of minimal depth of neuromuscular blockade | Use sugammadex to antagonize deep, moderate, and shallow neuromuscular blockade induced by aminosteroidal agents (rocuronium, vecuronium) (deep: post-tetanic count >1 and TOF count 0, moderate: TOF-count 1 to 3, shallow: TOF-count 4 and TOF-ratio <0.4) | |
| Advanced spontaneous recovery (i.e., TOF-ratio >0.2) before starting neostigmine-based reversal and to continue quantitative monitoring of neuromuscular blockade until a TOF-ratio of more than 0.9 has been attained | ||
| Conditionally recommended (due to low strength of evidence) | In the use of atracurium or cisatracurium and minimal depth of neuromuscular blockade, consider using neostigmine to avoid residual blockade | |
| In the absence of quantitative monitoring, after using neostigmine for blockade reversal, wait at least 10 min before extubation | ||
| ASA – American Society of Anesthesiologists; ESAIC – European Society of Anaesthesiology and Intensive Care; RSII – rapid sequence induction intubation; TOF – train-of-four; TOFR – train-of-four ratio; NMM – neuromuscular monitoring. | ||