Surgical risk-assessment tools

A 55-year-old man is awaiting a transjugular intrahepatic portosystemic shunt procedure.

Considering the Child–Pugh classification of liver disease, of the following

clinical features, which one does NOT score two points?

a) Ascites controlled with diuretics

b) Encephalopathy grade II

c) Bilirubin 42 micromol/L

d) Albumin 27 g/L

e) INR 2.4

Answer: e

Explanation

The Child–Pugh (or Child–Turcotte–Pugh) score is a risk-stratification tool used to

predict mortality associated with surgical procedures on patients with liver disease,

although originally was described for use with patients awaiting portocaval shunt

surgery. Five criteria each score one to three points giving a summed score with a

minimum of five and a maximum of fifteen. A score of five to six is labelled Child’s

A, seven to nine is Child’s B and ten to fifteen is Child’s C with a progressively

worse prognosis and mortality as the score rises. Other factors determining outcome

are the patient’s comorbidity and the nature of the proposed surgery. An INR of 2.4

would score three points. The patient in the question would, with those features

described, score eleven translating to Child’s C liver disease and a peri-operative

mortality of >75% (for intra-abdominal surgery). Child’s C one-year mortality, without

intervention, is 50%. In many spheres the Child–Pugh score is being replaced by

the MELD score (Model for End-stage Liver Disease). This excludes subjective

assessment of the degree of ascites and encephalopathy, requiring only the patient’s

bilirubin, INR and creatinine (adjusted for use of renal replacement therapy). These

data are inserted into a formula as their natural logarithms and a score is generated.

Originally introduced for prognostication following transjugular intrahepatic portosystemic

shunt (TIPS), MELD has been applied and validated to most surgeries

contemplated for patients with active liver disease. Transjugular intrahepatic portosystemic

shunt is associated with poor outcome if the MELD score is >24, thus

historically would be avoided in these circumstances. Regarding the patient in the

question, their serum creatinine would have to be less than 140 micromol/L to

achieve a MELD score of <24.