6901 Hepatic, Pancreatic, Splenic Flashcards
1
Q
Difference between endocrine and exocrine gland?
A
endocrine gland secretes diff types of hormones directly into bloodstream; exocrine secretes hormones by way of a duct to an environment external of itself
2
Q
What type of gland would secrete a hormone that is transported along a nerve tract?
A
endocrine
3
Q
Secretin is released in response to what? And what does it do?
A
flood of acid in to small intestine/duodenum d/t released liquified ingesta from the stomach; stimulates pancreas and bile ducts to release a flood of bicarb base
4
Q
Principal target for secretin?
A
pancreas
5
Q
Bicarb rich fluid (stimulated by secretin) from the pancreas flows in to the SI thru?
A
pancreatic duct
6
Q
In addition to the pancreas, secretin stimulates what to release bicarb and which is more important, the pancreaseor this other one?
A
bile duct cells; pancreas
7
Q
Secretion of secretin is turned off when?
A
as acid is neutralized by bicarb and returns to normal state
8
Q
Anticholinergic drugs like atropine and glycopyrrolate may induce what type of response to secretin?
A
decreased response
9
Q
A surgery that is rarely done any more but causes decrease in bicarb secretion in response to acidic duodenum?
A
vagotomy
10
Q
Two functions of pancreas?
A
endocrine and exocrine
11
Q
Pancreas’ exocrine function?
A
continuous secretion of 1500-3000 mL of pancreatic fluid daily
12
Q
Endocrine function of pancreas secretes what 3 things?
A
insulin; secretin; glucagon
13
Q
How many U/day does the normal adult secret?
A
50U
14
Q
Endocrine secretion from pancreas is controlled by what 2 “systems”?
A
hormonal; PNS
15
Q
Why are g coupled protein receptors called transmembrane receptors and seven transmembrane receptors?
A
transmembrane because they pass thru the cell membrane and 7 transmembrane because they pass thru the cell membrane 7 times
16
Q
What type of receptors activate g protein coupled receptors and name some examples of these receptors which activate g protein?
A
ligand; light sensitive compounds, odors, pheromones, hormones, NTs
17
Q
Basic way in which g protein coupled receptor works?
A
ligand binds to certain sites on g protein receptor and g protein receptor causes 2nd pathway to begin to elicit some response from the cell
18
Q
What kind of hormone is insulin?
A
peptide
19
Q
Insulin is central to regulating?
A
carbohydrate and fat metabolism
20
Q
Insulin causes cells in what 3 body parts to take up glucose from the blood?
A
liver, skeletal muscles, fat tissue
21
Q
Glucose is stored as what in skeletal muscles and liver? And as what in adipocytes?
A
glycogen; triglycerides
22
Q
How does insulin stop the use of fat as an energy source?
A
inhibiting release of glucagon
23
Q
What is the process called that the body uses to use stored sugaras an energy source when blood glucose levels fall?
A
glycogenolysis
24
Q
Glycogenolysis breaks down the sugar stored in what 2 organs to use as glucose?
A
liver and muscles
25
What % of Type II diabetics require insulin as part of their medications?
>40%
26
Insulin is also used as a control to other body systems to stimulate what for example?
amino acid uptake by body cells
27
What else does secretin control besides secretions in to duodenum, and where is this?
water homeostasis; hypothalamus, pituitary, kidney
28
Where is secretin produced?
S cells of duodenum in crypts of Lieberkuhn
29
Secretin stimulates secretion of what 3 things from where?
bile from liver; alkaline pancreatic juice from pancreas; bicarb from duodenal Brunner's glands
30
This controls plasma levels of insulin and glucagon?
somatostatin
31
Primary endocrine function of pancreas?
regulate glucose control
32
What does glucagon do and which cells release it?
opposes insulin secretion; alpha cells
33
What does insulin do to fat metabolism?
suppresses it
34
What do delta cells of islets of langerhans secrete?
somatostatin (growth hormone releasing inhibitory factor)
35
Alpha, beta adrenergic, and beta cholinergic stimulation do what to insulin?
inhibits insulin secretion
36
3 stimulants which cause insulin secretion?
vagal stimulation, B2 adrenergic stimulation, cholinergic drugs
37
Some causes of acute pancreatitis (8)?
alcohol, trauma, ulcerative penetration from adjacent structures (duodenum), infection, biliary tract disease, metabolic disorders (hyperlipidemia, hypercalcemia), drugs, surgery
38
4 drugs which cause acute pancreatitis?
corticosteroids, furosemide, estrogens, thiazide diuretics
39
2 surgeries which can cause post op pancreatitis?
mobilization of abdominal viscera, cardiopulmonary bypass
40
First symptom of pancreatitis? And describe it?
pain; localized, radiating, dull, severe; mid epigastric to periumbilical and may be worse when supine
41
Other symptoms of acute pancreatitis?
N/V, abdominal distention, fever, hypotension, ARF, hypocalcemia with EKG changes (prolonged QT)
42
How does pancreatitis induce autodigestion?
edema, hemorrhage, necrosis of pancreas
43
What causes the pancreatic pain?
obstruction and distention of pancreatic ducts, edema with stretching of pancreatic capsule, edematous duodenal obstruction, biliary tract obstruction, chemical peritonitis, inflammatory exudates, blood and enzymes in the retroperitoneum
44
Common causes of chronic pancreatitis (3)?
chronic alcohol, pancreatic trauma at early age, chronic biliary tract disease
45
Diagnosis triad for chronic pancreatitis?
steatorrhea, pancreatic calcification, diabetes mellitus
46
2 common characteristics of chronic pancreatitis?
malnourished, male>female
47
2 complications from chronic pancreatitis and what are they defined as?
pseudocyst: abnormal collection of fluid 8%; pancreatic abscess 3-5% and mortality >90% if ruptures
48
What organ commonly becomes diseased in chronic pancreatitis?
liver
49
What are 6 s/s of hepatic disease in chronic pancreatitis pt?
jaundice, ascites, esophageal varices, derangements in coagulation factors, serum albumin, and transferase enzymes
50
Chronic pancreatitis patients are at a predisposition for developing?
pericardial and pleural effusions
51
Why is a pancreatic abscess so bad in chronic pancreatitis?
it can cause severe intraabdominal hemorrhage
52
What is the surgical therapy for pancreatitis?
drainage of a pseudocyst
53
When is a surgical drainage of a pseudocyst usually done?
after the cyst matures (usually 6 weeks)
54
Most common indication for pancreatic surgery?
tumor
55
2 types of pancreatic tumors requiring surgery?
adenocarcinoma, insulinoma
56
90% of pancreatic adinocarcinomas are?
ductal
57
If the patient is jaundiced and needing pancreatic surgery, he or she probably has?
biliary obstruction
58
Insulinoma is cancer of which cells and what are s/s? What is treatment?
beta; hypoglycemia, hypersecretion of insulin; distal, subtotal, or total pancreatectomy (Child's Procedure)
59
A pancreatic tumor is resectable if?
it's not invading blood vessels or hepatobiliary tree
60
If a pancreatic tumor is resectable, what is the procedure called to remove it?
pancreaticoduodenectomy
61
What is an ERCP in relation to pancreas?
can obtain biopsy of carcinoma
62
This surgery includes excision of the antrum of the stomach with the duodenum, distal bile duct, and pancreatic head, reconstruction with choledochostomy, pancreaticogastrojejunostomy
Whipple
63
This syndrome occurs when there is hypersecretion of gastrin, severe peptic ulcer disease, potential for perforation, erosion and hemorrhage, and treatment is surgical excision of the lesion?
Zollinger Ellison Syndrome (gastrinoma)
64
Biliary obstruction occurs with what type of pancreatic tjmor?
adenocarcinoma
65
In regards to a Whipple Procedure, both the head of the pancreas and the duodenum are removed why?
they share the same arterial blood supply (gastroduodenal artery)
66
What is Zollinger Ellison syndrome caused by?
non beta cell gastrin secreting tumor of the pancreas that stimulates the acid secreting cells of the stomach to maximal activity, with constant GI mucosal irritation
67
What syndrome can ZES be a part of?
MEN 1
68
In ZES can tumors be elsewhere than the pancreas?
yes
69
ZES is also known as?
gastronoma
70
Treatment for gastronoma/ZES?
complete pancreatectomy
71
What is taken out on pancreatectomy?
parts of duodenum, antrum of stomach, gall bladder, common bile duct, complete pancreas and pancreatic duct, hepatojejunostomy, duodenojejunostomy
72
4 anesthetic characteristics of ERCP?
conscious sedation, MAC, or GA (most likely bc control of airway is better), pt is semi lateral or prone, glucagon to relax sphincter of oddi (0.4-1 mg IV), usually 1-4 hour cases, stent cases quicker
73
8 anesthetic considerations for pt with pancreatic disease?
ileus (aspiration precautions), glucose monitoring bc glucose metabolism is off, lyte disorders, frequent coagulation draws, potential blood produce and crystalloid resuscitation, pulmonary complications (pleural effusions), maintain renal function/perfusion- UO 0.5-1 mL/kg/hr, most procedures done under GA +/- a line, epidural, PA cath
74
Anesthetic plan for pt with pancreatic disease depends on?
health of pt and comorbidities
75
4 lyte disorders that may be present in pt with pancreatic disease?
hypocalcemia, hypomagnesemia, hypokalemia, hypochloremic metabolic alkalosis
76
ERCP diagnoses and treats certain problems of?
biliary or pancreatic duct systems
77
ERCP can be done to diagnose and treat conditions of the bile ducts and examples of this are?
gall stones, inflammatory strictures (scars), leaks (from trauma and surgery), and cancer
78
Pancreatic transplant is becoming an option for what type of patients? Uremic patients will have simultaneous transplant of what organ in addition?
insulin dependent diabetic patients refractory to medical management; kidney
79
1 year graft and patient survival rates of pancreas transplant are?
70%; 91%
80
Operative considerations for pancreatic transplant pt?
a line, +/- CPV/ PA, frequent blood glucose checks (q30 min), blood gas monitoring, admin of immunosuppressive drugs, use colloid to prevent graft edema, common occurrence of metabolic acidosis r/t systemic hypoperfusion
81
What is the goal for crystalloids in pancreatic transplant pt and why?
82
In pancreatic transplant patients, you should evaluate for degree of 2ndary diabetic complications before surgery such as?
ischemic cardiac disease, renal insufficiency, peripheral neuropathies/autonomic neuropathies
83
Airway eval in pancreatic transplant pt- look out for?
increased difficulty in intubation of diabetic patients
84
Since there is a high incidence of renal disease in pancreatic transplant patients, you should evaluate what 2 things preop?
last dialysis/ K level and other lytes
85
Autonomic and systemic neuropathies in pancreatic transplant patient manifest as?
wide swings in HD stability (severe refractory bradycardia), gastroparesis (vagal neuropathy), risk of hyperkalemia with suxxs admin (motor and sensory neuropathy)
86
5 s/s to assess for preop in pancreatic transplant pt?
diarrhea, bloating, hypotension on initiation of dialysis, esophageal dysfunction, dizziness with position change
87
Easiest way to assess for autonomic neuropathy?
take BP lying down and flat
88
What's the functional unit of the liver? And how many of them are there in liver?
hepatic lobule; 50,000-100,000
89
Blood supply to liver is from what 2 things?
hepatic artery and portal vein
90
How many mL of blood/min and what % of CO does liver receive?
1500 mL blood/min; 25-30% CO
91
What % of blood flow from the hepatic artery and portal vein goes to the liver?
25-30% of hepatic artery flow; 70-75% portal vein flow
92
7 functions of the liver?
bile production, protein synthesis, glycogen storage, protein metabolism, insulin clearance, lactate conversion in to glucose, drug metabolism and transformation
93
Liver is innervated by which nerves?
splanchnic nerves derived from spinal nerves T3-T11
94
What type of adrenergic receptors are present in hepatic arterial circulation?
alpha and beta
95
Which adrenergic receptors are in the hepatic/portal vein?
only alpha
96
Hepatic arterial flow is autoregulated in accordance with?
metabolic demand
97
Portal blood flow is dependent on?
combined venous outflow from spleen and GI tract
98
Largest organ and largest gland in human body?
liver
99
The liver is located in what quadrant and rests just below the?
right upper quadrant; diaphragm
100
The liver lies to the right of the? And overlies the?
stomach; gallbladder
101
Hepatic artery carries blood from the?
aorta
102
Hepatic vein carries blood containing?
digested nutrients from entire GI tract, spleen, and pancreas
103
The hepatic artery and portal vein subdivide in to? Which supply?
capillaries; lobules of liver
104
The hepatic lobule is also known as?
acinus
105
The acinus architecture radiates around?
a single vein which empties in to hepatic veins and then in to vena cava
106
Oxygen is provided to the liver by?
hepatic artery (1/2) and portal vein (1/2)
107
Blood flow in the liver flows thru what? and then empties in to what?
sinusoids and then empties in to central vein
108
The central veins coalesce in to what? And then leave the liver via?
hepatic veins; vena cava and return the blood to the right atrium
109
Which 2 ducts make up the common bile duct?
cystic duct from gall bladder and common hepatic duct
110
Describe the visceral peritoneum of the liver and what part of the liver does it not cover?
it's a thin, double layered membrane that reduces friction against other organs; does not cover the patch that connects to the diaphragm
111
What's the function of the triangular ligaments in the liver? And what is the exception?
none other than as anatomical landmarks; falciform ligament attaches liver to posterior portion of anterior body wall
112
Bile drains directly in to duodenum via? Or bile can be temporarily stored in _____ via _____?
common bile duct; gall bladder, cystic duct
113
Common bile duct and pancreatic duct enter the 2nd part of the duodenum together at the?
ampulla vader
114
Which liver lobe is typically singularily taken from donor?
left
115
Blood from the gut is cleansed of its colonic bacilli by what cells in the liver?
Kupffer cells (macrophages)
116
Where do the Kupffer cells lie?
they line the hepatic sinuses
117
Why is it that in the liver a large quantity of lymph is nearly equal to the protein concentration of the plasma?
endothelial cells line the hepatic sinuses permit diffusion of large plasma proteins and other substances in to extravascular space in the liver
118
The hepatic artery delivers how many mL/min of portal oxygenated blood?
400-500 mL/min
119
Since there is a double afferent blood supply of oxygenated blood to the liver, what % of blood is deoxygenated venous blood supplied from the portal vein?
75-80%
120
The portal vein collects blood that leaves which organs?
spleen, stomach, SI, LI, gallbladder, and pancreas
121
Does blood entering the liver via the hepatic portal vein contain oxygen? It is very high in what?
yes; nutrients from the digestive tract and mesenteric and portal veins
122
Why is the liver relatively resistant to hypoxia?
dual blood supply
123
Cells that line the sinusoids in the liver?
epithelial cells and Kupffer cells
124
Hepatic veins empty in to what?
inferior vena cava
125
Range of portal vein pressure?
6-10 mm Hg
126
The mean pressure in the hepatic artery is similar to?
that in the aorta
127
What's the significance of the relatively low pressure in the portal vein?
it serves as a blood reservoir; it may expand in cardiac failure, it serves as reservoir when bleeding, compensates for up to 25% of hemorrhage by immediate expulsion of blood
128
Portal blood flow is dependent on combined venous blood flow of?
from spleen and GI tract
129
Do anesthetics alter hepatic integrity?
no
130
Why is it that hepatic artery or venous blood flow may not result in an overall change in total hepatic blood flow?
reciprocal autoregulatory mechanism/ HABR (hepatic artery buffer response)
131
HABR works by?
changes in hepatic artery or portal vein blood flow may not result in an overall change in hepatic blood flow
132
All intraabdominal organs are drained in to?
superior mesenteric vein and hepatic portal vein
133
What is gluconeogenesis? What stimulates it?
formation of glucose from noncarb molecules lactate and pyruvate and amino acids; reduction of glycogen stores
134
During periods of fasting, the liver maintains glucose levels at normal levels by what?
glycogenolysis
135
What is glycogenolysis and what stimulates it?
process of liberating glucose from glycogen stores found in the liver and skeletal muscle; epinephrine and glucagon
136
Hypoglycemia occurs in liver patients for what 3 reasons?
derangements in insulin clearance, decrease in glycogen capacities, impairment in gluconeogenesis
137
With the exception of what, protein synthesis mostly occurs in the liver?
immunoglobulins
138
What typically happens to plasma oncotic pressure in liver patients?
decreases
139
Why is there a larger Vd in liver patients?
decreased oncotic pressure result in overextension of interstitial space and 3rd spacing
140
What does a decreased protein level mean for NDMR?
needs to be increased d/t larger Vd
141
What implications does suxxs have in a liver failure patient?
plasma cholinesterase may be deficient which may prolong the effects of suxxs and enhance the potential toxicity of ester anesthetics
142
Roles in protein metabolism in the liver excluding albumin and thrombopoeitin?
synthesis of lipoproteins (important for lipid transport in the blood), deamination of amino acids in to carbs and fats for production of ATP and production of urea for removal of ammonia
143
How does the liver aid in intestinal digestion?
forming bile and secreting it in to the common bile duct
144
5 functions of liver?
carb metabolism, protein synthesis, amino acid synthesis, protein metabolism, bile production
145
What's the end product of hemoglobin metabolism?
conjugated bilirubin
146
What continuosly secretes fluid in the liver that contains phospholipids, cholesterol, conjugated bilirubin, bile salts, and others?
hepatocytes
147
Where is bile stored and concentrated?
gall bladder
148
What hormone releases bile in to the gallbladder?
CCK
149
What initiates contraction of the gall bladder and movement of bile via the common bile duct?
presence of fat and protein in the duodenum
150
Where does the common bile duct merge with the pancreatic duct?
ampulla of vater
151
How does the ampulla of vater empty in to the duodenum?
sphincter of oddi
152
Bile secretions assists in absorption of what 2 things and removal of?
fat and fat soluble vitamins (A, D, E, K); metabolic end products such as those of drugs
153
Impaired bile production or flow may lead to what 3 things?
steathorrhea, vit K deficiency, delayed removal of active drug metabolites
154
The liver is responsible for producing all clotting factors except?
VIII
155
5 more functions of the liver?
lipid metabolism, coagulation factor synthesis, insulin clearance, drug metabolism/transformation, bilirubin metabolism
156
Main site for insulin clearance?
liver
157
The enzyme systems involved in biotransformation of drugs are located primarily in the ______ and also in the _______?
liver; lung
158
Bilirubin is a breakdown product of?
heme metabolism
159
Which bilirubin is toxic in high levels and not soluble in water?
unconjugated
160
What system is primarily responsible for Phase I reactions?
CYP 450
161
The type of phase reaction is important for metabolizing many of the anesthetic drugs?
Phase I
162
One word difference between Phase I and Phase II reaction?
Phase I: functionilization; Phase II: conjugation
163
Morphine and acetaminophen are metabolized by what phase reaction?
II
164
What happens in a phase I reaction?
add or exposure a functional group (oxidation, reduction, hydrolysis)
165
With the exception of a prodrug, what typically happens to pharmacologic activity in a Phase I reaction?
loss of pharmacologic activity
166
What happens in a Phase II reaction?
Phase I product (substrate) conjugates with a 2nd molecule
167
In this type of drug reaction a covalent bond is formed between a functional group and glucuronic acid, sulfate, glutathione, amino acid, or acetate
Phase II
168
What % of drugs are manufactured by CYP450?
50%
169
When 2 drugs are administered and metabolized by the same enzyme system, what happens to the rate of metabolism?
can be increased or decreased
170
Regarding CYP450, enzyme induction hastens metabolism in coadminstered drugs like?
ketamine, benzos, barbs, ethanol
171
Regarding CYP450 enzyme induction promotes tolerance to meds like?
sedatives, opioids, steroid muscle relaxants
172
Coadministration of drugs metabolized by a single CYP will compete for binding to enzyme's active site. 2 examples of drugs like this are?
cimetidine, chloramphenicol
173
Mild elevations in what 3 serum concentrations are common following surgical procedures regardless of the type of anesthesia used, and they usually resolve without further consequences?
serum aminotransferase, alkaline phosphatase, bilirubin
174
5 risk factors for mortality r/t liver disease?
high child-pugh score, ascites, elevated serum creatinine, preop upper GI bleed, high ASA rating
175
3 types of hepatitis?
acute, chronic, drug induced
176
3 causes of acute hepatitis?
viral, hepatotoxic substance, adverse drug reaction
177
2 causes of drug induced hepatitis?
alcohol, acetaminophen
178
Patients have 1 of 3 syndromes in chronic hepatitis? Which one is the worst?
chronic persistent, chronic lobular, chronic active; chronic active
179
2 labs which would indicate normal liver function in patient who has been postponed d/t abnormal liver ftn?
LFTs, platelets
180
2 things which increase morbidity and mortality for liver patients?
acute intoxication and acute viral hepatitis
181
Alcoholics in DTs have what mortality rate?
50%
182
5 anesthetic considerations for alcohol in DTs?
decreased anesthetic required, aspiration precautions, platelet aggregation inhibited, brain more sensitive to hypoxia, increased circulating catecholamines
183
3 lab tests in severe liver disease?
increased PT, decreased albumin, low platelet count
184
S/s of severe liver disease?
encephalopathy, bleeding diatheses, jaundice, ascites, HD findings
185
Preanesthetic considerations for pt w liver disease (5)
blood typing and availability, correct dehydration, correct lyte issues, correct coagulation probs, premedicate with benzos and thiamine if suspecting acute withdrawal
186
Child Turcotte Pugh Score contains what 6 items?
encephalopathy, ascites, bilirubin, albumin, PT, for PBC/PSC
187
What does portal hypertension interfere with?
liver's metabolic and synthetic processes
188
What electrolyte disturbance is common in cirrhosis?
metabolic alkalosis
189
3 examples of direct liver injury?
alcoholism, viral hepatitis, autoimmune hepatitis
190
Indirect injury to liver occurs via damage to what?
bile duct
191
Some causes of indirect injury to the liver?
biliary cirrhosis, sclerosing cholangitis, biliary atresia,
192
Indirect cause of cirrhosis in infants?
biliary atresia
193
2 inherited disorders that result in abnormal storage of metals in liver leading to tissue damage and cirrhosis?
Wilson's disease; hemochromatosis
194
Disease where patients store too much copper in the liver, brain, kidneys, and corneas of eyes?
Wilson's disease
195
Most common cause of portal HTN?
cirrhosis
196
What 2 factors impact development of portal HTN?
vascular resistance and blood flow
197
When portal HTN rises above what, varices and ascites can result?
12 mm Hg
198
Main complication of portal HTN?
esophageal varices
199
Main complication of portal HTN is _____ and it is caused by _______?
GI hemorrhage; esophageal varices
200
The response to increased venous pressure regarding the liver is?
development and engorgement of collaterals---> varices
201
Cirrhosis is generally associated with what 3 major complications?
variceal hemorrhage from portal HTN, fluid accumulation in form of ascites and hepatorenal syndrome, hepatic encephalopathy or coma
202
9 common s/s cirrhosis?
hepatic encephalopathy, esophageal varices, skin spider angiomas, malnutrition, splenomegaly, periumbilical caput medusa, ascites, hemorrhoids, testicular atrophy
203
CV systemic considerations for cirrhosis pt?
hyperdynamic state, increased CO, decreased SVR, increased endogenous vasodilators, alcoholic CM, CHF,anemia, thrombocytopenia, AV shunting with portal HTN and angiogenesis
204
Respiratory systemic considerations in cirrhosis pt?
hepatopulmonary syndrome: pleural effusions, pul HTN, COPD 2ndary to smoking, ascites may interfere with diaphragm, R-L shunting may cause hypoexmia (up to 40% of CO)
205
4 mechanisms responsible for ascites?
portal HTN, hypoalbuminemia, seepage of protein rich lymphatic fluid, renal Na retention
206
When is ammonia produced?
when proteins are digested
207
Patients with cirrhosis and ascites have what 4 things?
decreased renal perfusion, altered intrarenal HDs, enhanced proximal and distal Na reabsorption, impairment of free water clearance
208
5 risk factors for hepatorenal syndrome?
BP that falls when person rises or suddenly changes position, diuretics, GI bleed, infection, recent paracentesis
209
What's the term for nitrogen waste product build up in person with hepatorenal syndrome?
azotemia
210
List some anesthetic concerns with liver disease pt?
hypoglycemia, vit K deficient coagulopathies, platelet sequesteration and thrombocytopenia, splenomegaly, decreased oncotic pressure, ascites, 3rd spacing, large Vd, pulmonary issues d/t ascites, espophageal varices, GI bleeding
211
4 factors which are deficient for clotting in liver disease pt (these were bolded)?
II, VII, IX, X
212
Why should you be careful with positive pressure ventilation in liver disease pt?
can worsen already poor venous return which decreases CO
213
Why do you have to be careful with OG/NGT insertion in liver disease pt?
esophageal varices
214
Most anesthetics do what to hepatic/splanchic blood flow and how does that effect drugs?
decrease; may cause drugs to be metabolized slower
215
Drugs that induce enzymatic pathways will be metabolized at what rate? How do you adjust the drug?
more quickly; give more
216
Drugs that inhibit enzymatic pathways will metabolize at what rate? What do you have to do to the drug?
more slowly; less drug
217
Drugs that use similar pathways may what to each other?
inhibit or enhance
218
Deficient plasma cholinesterase may prolong effects of what 3 drugs?s
suxxs, esmolol, ester local anesthetics
219
What should you do to the NMDR dose in liver disease pts and why?
increase bc larger Vd
220
This anesthetic gas causes the greatest reduction in hepatic blood flow?
halothane
221
How does halothane cause a reduction in hepatic blood flow?
hepatocyte hypoperfusion, hypersensitive immune response
222
Halothane is more likely to occur with what exposure?
1st, 2nd, 3rd
223
Why do you want to avoid sphincter of oddi spasms in liver disease pt?
increase in biliary pressure
224
Some meds that cause sphincter of oddi spasms?
morphine>meperedine>butorphanol>nalbuphine
225
Preferred narc to not induce sphincter of oddi spasms?
fentanyl
226
3 other causes of sphincter of Oddi spasm?
surgical manipulation, cold irrigation, contrast dye
227
3 meds to give to liver disease pt w ascites and edema?
albumin, mannitol, K sparing diuretics
228
What does encephalopathy form accumulation of toxins like ammonia and nitrogenous compounds mean for some anesthetic drugs?
breaks down BBB, increased levels of GABA (inhibitory) so very susceptible to depressant mechanism, cerebral uptake of benzos is greatly enhanced
229
Acceptable hematocrit in liver disease pt is?
30%
230
Acceptable platelet count in liver disease pt before surgery?
>100,000
231
What 3 blood products should be available besides PRBC for liver disease pt before surgery to correct coagulopathies?
cryo, FFP, platelets
232
What liver disease characteristic makes the need for asceptic technique mandatory?
leukopenia
233
Is regional anesthesia ok in liver disease pt?
yes if no coagulopathies
234
9 goals for intraop management of GA in liver disease pt?
aspiration precautions, standard monitors, large IVs, PA cath, a line, CVP, TITRATE drugs (give a LITTLE and see what happens), correct coagulopathies, maintain perfusion to hepatocytes to prevent further damage, normothermia, maintain UO
235
Why do you have to preserve hepatic arterial blood flow so badly?
portal venous blood flow is reduced and it is dependent on hepatic artery perfusion
236
Is suxxs acceptable in liver failure?
yes, just know it may be prolonged
237
3 types of meds that are highly protein bound and should have the dosage reduced in liver disease pts?
benzos, barbs, some opiates
238
Good choice for paralytic in liver disease pt?
cis
239
Volatile agent of choice in liver disease pt?
isoflurane; no sevo bc Fl ion production
240
Why is fentanyl a good opioid in liver disease pt?
least effect on hepatic blood flow, O2 supply, O2 consumption
241
Other good opioids besides fent in liver disease pt?
sufenta, alfenta, remifent
242
3 things to AVOID in liver disease pt bc they reduce hepatic blood flow?
hypotension, excessive sympathetic activation, high mean airway pressures
243
How do vasopressin and somatostatin treat esophageal varices?
they're splanchic vasoconstrictors
244
Dose of vaso or somatostatin? What do you need to do to prevent systemic HTN during that administration?
0.1-0.4U/min infusion; NGT/OGT
245
Treatment of esophageal varices that compresses the varices?
triple lumen sengstaken blakemore tube
246
How does ocreotide treat esophageal varices?
it's a somatostatin analogue; inhibits GI peptide hormone activity which decreases gut motility and venous return to portal circulation
247
Dose of ocreotide?
50 mcg/hr infusion
248
Whats the rebleed rate on sclerotherapy for esophageal varices, and it is done under what type of anesthesia?
60%; conscious sedation
249
What is the TIPS procedure?
placement of a catheter thru the IJ into the vena cava and in to the brach of the hepatic vein done under fluoro (allows for portal decompression)
250
What anesthesia is TIPS done under?
conscious with local
251
How are the anesthetic considerations for TIPs patient different from liver disease pt anesthetic considerations?
they're the same
252
What's the EBL in TIPS procedure?
potential for large
253
Monitors during TIPS?
a line, CVP, PA cath, UO
254
Target PaCO2 in TIPS pt and why?
> or = 40 to maintain portal blood flow
255
Is N2O ok in TIPS pt?
no
256
Fluid management in TIPS patient?
use large amts of albumin, LR controversial bc could exacerbate liver failure d/t bicarb breakdown in liver, NS can encourage Na retention, avoid Lasix and other diuretics if possible, if need diuretic use Mannitol to keep UO 50 mL/hour
257
Complications of TIPS?
liver laceration, massive hemorrhage, gall bladder perf, renal failure from contrast dye
258
Key for liver transplantation surgery?
immunosuppressive therapy such as cyclosporine and tacrolimus
259
Anesthetic considerations for liver transplant pt?
same as liver disease, HD consequences of clamping and unclamping portal vein and vena cava, alterations in metabolism and coagulopathy
260
What are 2 risks/complications during liver transplant when perfusion of emplaced graft?
hyperkalemia, VAE
261
Anticipate what type of blood loss in liver transplant?
large; have platelets, cryo, FFP
262
What type of monitoring do you want for liver transplant pt?
invasive monitoring; large bore IVs, possibly 8.5 F AC RIC line
263
2 lyte abnormalities for liver transplant?
hyperk, hypoca
264
What antiHTN agents should you avoid in transplant pts?
long acting
265
What is specific about HD monitoring in liver transplant pt?
2 sites are often used for arterial monitoring
266
What type of monitoring is useful to detect for postpulmonary syndrome, reperfusion crisis, and suspected tamponade, as well as general cardiac function and fluid status?
TEE
267
This test is indicated in a liver transplant pt if they're in fulminant liver failure with advanced encephalopathy if coagulopathy can be corrected?
intracranial pressure monitoring
268
Some labs that are indicated for coagulation profiles in liver transplant patient?
PTT, PT, fibrinogen levels, degradation levels, platelet count
269
What lab tests allows for factor specific determinations of abnormalities and therapeutic responses
factor activity
270
This test allows bedside eval of coagulation with patterns typical of factor and platelet deficiency and fibrinolysis
TEG
271
What 4 things does TEG tell you?
when clot starts, how long does it take for the clot to organize itself, clot strength, how long it takes for the clot to dissolve/fibrinolysis
272
How much blood product should be available for liver transplant?
10-20 U PRBC, FFP, plasma
273
What is commonly used in liver transplant when cancer or infection is not suspected and is r/t preventing bleeding?
cell savage
274
Negative about cell salvage?
large volumes of processed cells may dilute platelets and coagulation factors; effect on fibrinolysis is controversial
275
What is it called when flow from femoral and portal vein to axillary or IJ maintains venous return during caval interruption?
venovenous bypass
276
What % of liver can be resected?
80-85%
277
What's the blood loss anticipated in hepatic surgery?
large
278
What type of CVP may be desirable in liver resection surgery to reduce the amt of bleeding?
lower
279
3 indications for hepatic surgery?
repair of lacerations, drainage of abscess, and resections for tumors
280
Some antifibrinolytics to be used during hepatic surgery?
amicar; aprotinin
281
What type of sugar levels would you expect in liver surgery pt?
hypoglycemia
282
Blood flow to the spleen?
300 mL/min
283
3 zones of the spleen?
white pulp, red pulp, marginal zone
284
Where does the spleen lie?
9th-11th rib, between the fundus of the stomach and the diaphragm
285
2 surfaces of the spleen?
diaphragmatic and visceral
286
Part of spleen which consists of splenic sinusoids (large thin walled vessels)
red pulp
287
Part of spleen which contains the end arterial branches of central arteries and contain lymphocytes, macrophages, and plasma cells
white pulp
288
Zone of spleen which contains the vascular space with the white pulp and red pulp?
marginal zone
289
What;s the nerve supply to the spleen?
sympathetic fibers are derived from the celiac plexus
290
The spleen is made up of what 4 components?
red pulp, white pulp, supporting tissue, vascular system
291
This part of the spleen is fibroelastic and forms the capsule, coarse trabeculae, and a fine reticulum?
supporting tissue
292
The white pulp/lymph nodules are arranged around an eccentric arteriole called?
Malpigian corpuscle
293
The lymphocytes in the spleen are freely transformed in to?
plasma cells, which can produce large amounts of antibodies and immunoglobulins
294
Red pulp in the spleen is where?
in between the sinusoids
295
3 types of cell population in spleen?
lymphocytes, fixed and free macrophages, blood cells
296
3 physiologic functions of the spleen?
hematopoiesis in fetus, blood filtering, immune processing of blood borne foreign antigens,
297
One of spleens most important functions?
phagocytosis
298
Phagocytes in the spleen remove what?
debris, old RBCs and other cells, and microorganisms
299
Phagocytosis in spleen initiates what response (immune related)?
humoral and cellular
300
What % of RBCs are present in the spleen?
8%
301
Splenectomy is treatment of what 5 things?
ITP, TTP, hodgkin's disease, lymphoma, some leukemias, hemolytic anemia, hypersplenism, spheroctyosis, sickle cell disease, traumatic injury
302
This disease causes extensive microscopic clots to form in the small blood vessels thus causing organ damage?
TTP
303
A bleeding condition in which the blot doesn't clot as it should and a splenectomy is treatment?
ITP
304
Anesthetic considerations for spleenectomy?
hematologic analysis, large IV, standard monitoring, transfuse as appropriate, careful positioning, appropriate fluid admin, maintain UO, h/h levels, other monitoring depends on pt condition
305
Is there a lot of blood loss anticipated in splenectomy?
yes
306
Where are 2/3 of carcinoid tumors?
GI tract
307
Carncinoid tumors are composed of what cells?
enterochromaffin cells (Kupffer cells)
308
Some bioactive substances secreted by carcinoid tumors?
serotonin, histamine, kinin peptides, dopamine, substance P, gastrin, somatostatin, calcitonin, ACTH and others
309
Non GI sites of carcinoid tumor locations?
thymus, lungs, pancreas, liver
310
2 factors which enhance release of carcinoid syndrome?
direct stimulation, beta adrenergic stimulation
311
Why do most carcinoid tumors not produce symptoms?
75% are in GI tract and they're released in to portal circulation and destroyed by the liver
312
Increased serotonin levels may increase the release of what catecholamine and have what cardiac effects?
norepi; inotropy, chronotropy, vasoconstriction or vasodilation, HTN (and sometimes hypotension)
313
Elevated serotonin levels do what in the gut and what to ions?
stimulate gut motility and increase secretion of water, Na, Cl, and K from SI
314
4 s/s from elevated serotonin?
bronchospasm, hyperglycemia, vomiting, prolonged drowsiness after emergence from anesthesia
315
Histamine can produce what 2 things in carcinoid syndrome pts?
bronchospasm and flushing
316
4 s/s from bradykinin?
bronchospasm, flushing, hypotension (d/t vasomotor relaxation),
317
2 substances responsible for cutaneous flushing in carcinoid syndrome pt?
kinines, histamine
318
3 substances responsible for bronchospasm in carcinoid syndrome pt?
serotonin, bradykinin, substance P
319
4 substances responsible for profuse diarrhea in carcinoid syndrome?
serotonin, prostaglandins, substance E and F
320
3 effects carcinoid syndrome produces on heart/heart disease?
tricuspid regurg, pulmonic stenosis, SVTs
321
Bronchoconstriction in carcinoid syndrome pt is produced by what 3 things?
serotonin, bradykinin, substance P
322
Why would abdominal pain occur in carcinoid syndrome pt?
small bowel obstruction
323
Some other systemic manifestations of carcinoid syndrome?
hepatomegaly, hyperglycemia, hypoalbuminemia, right sided HF
324
Why would a carcinoid pt have skin lesions?
niacine deficiency
325
What prevents left sided involvement in carcinoid syndrome pt?
lung metabolism of serotonin
326
Diagnosis of carcinoid syndrome?
serotonin metabolites in the urine, elevated plasma levels of chromogranin A
327
Treatment of carcinoid syndrome?
surgical removal or management of symptoms
328
Some labs to get preop in carcinoid pt?
CBC, lytes, glucose
329
What meds can minimize effects of histamine in carcinoid pt?
H1 and H2 blockers
330
Most often used anesthesia for carcinoid pt?
general but all can be used
331
Serotonin antagonists used for carcinoid syndrome?
ocreotide and somatostatin
332
Dose of ocretotide and 1/2 life?
100 mcg SQ 2-3 times a day; 100 min
333
1/2 life of somatostatin?
2-3 min
334
How does somatostatin work?
it's an inhibitory peptide to antagonize and suppress release of tumor products; binds to receptor of tumor cells , resulting in decreased secretion
335
Good sedative meds used for induction in carcinoind pt?
etomidate, propofol
336
Good muscle relaxants in carcinoid pt?
vec, roc, cis
337
4 narcs good in carcinoid pt?
fent, remi, alfenta, sufenta
338
3 gasses used in carcinoid pt?
sevo, iso, des
339
Which reversal agents are good in carcinoid pt?
neostigmine, edrophonium
340
What do you have to avoid in carcinoid syndrome pt?
anything that could cause vasoactive release of substances from tumor
341
Avoid what 3 meds in carcinoid pt d/t kallikrinin release?
ketamine, epi, ephedrine
342
How should hypotension be treated in carcinoid pt?
alpha adrenergic like phenyl
343
what type of anesthesia does carcinoid pt need?
DEEP!
344
What may inhibit kallkreins and reverse carcinoid induced bronchospasm and hypotension?
aprotinin
