6901 Hepatic, Pancreatic, Splenic Flashcards
Difference between endocrine and exocrine gland?
endocrine gland secretes diff types of hormones directly into bloodstream; exocrine secretes hormones by way of a duct to an environment external of itself
What type of gland would secrete a hormone that is transported along a nerve tract?
endocrine
Secretin is released in response to what? And what does it do?
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
Principal target for secretin?
pancreas
Bicarb rich fluid (stimulated by secretin) from the pancreas flows in to the SI thru?
pancreatic duct
In addition to the pancreas, secretin stimulates what to release bicarb and which is more important, the pancreaseor this other one?
bile duct cells; pancreas
Secretion of secretin is turned off when?
as acid is neutralized by bicarb and returns to normal state
Anticholinergic drugs like atropine and glycopyrrolate may induce what type of response to secretin?
decreased response
A surgery that is rarely done any more but causes decrease in bicarb secretion in response to acidic duodenum?
vagotomy
Two functions of pancreas?
endocrine and exocrine
Pancreas’ exocrine function?
continuous secretion of 1500-3000 mL of pancreatic fluid daily
Endocrine function of pancreas secretes what 3 things?
insulin; secretin; glucagon
How many U/day does the normal adult secret?
50U
Endocrine secretion from pancreas is controlled by what 2 “systems”?
hormonal; PNS
Why are g coupled protein receptors called transmembrane receptors and seven transmembrane receptors?
transmembrane because they pass thru the cell membrane and 7 transmembrane because they pass thru the cell membrane 7 times
What type of receptors activate g protein coupled receptors and name some examples of these receptors which activate g protein?
ligand; light sensitive compounds, odors, pheromones, hormones, NTs
Basic way in which g protein coupled receptor works?
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
What kind of hormone is insulin?
peptide
Insulin is central to regulating?
carbohydrate and fat metabolism
Insulin causes cells in what 3 body parts to take up glucose from the blood?
liver, skeletal muscles, fat tissue
Glucose is stored as what in skeletal muscles and liver? And as what in adipocytes?
glycogen; triglycerides
How does insulin stop the use of fat as an energy source?
inhibiting release of glucagon
What is the process called that the body uses to use stored sugaras an energy source when blood glucose levels fall?
glycogenolysis
Glycogenolysis breaks down the sugar stored in what 2 organs to use as glucose?
liver and muscles
What % of Type II diabetics require insulin as part of their medications?
> 40%
Insulin is also used as a control to other body systems to stimulate what for example?
amino acid uptake by body cells
What else does secretin control besides secretions in to duodenum, and where is this?
water homeostasis; hypothalamus, pituitary, kidney
Where is secretin produced?
S cells of duodenum in crypts of Lieberkuhn
Secretin stimulates secretion of what 3 things from where?
bile from liver; alkaline pancreatic juice from pancreas; bicarb from duodenal Brunner’s glands
This controls plasma levels of insulin and glucagon?
somatostatin
Primary endocrine function of pancreas?
regulate glucose control
What does glucagon do and which cells release it?
opposes insulin secretion; alpha cells
What does insulin do to fat metabolism?
suppresses it
What do delta cells of islets of langerhans secrete?
somatostatin (growth hormone releasing inhibitory factor)
Alpha, beta adrenergic, and beta cholinergic stimulation do what to insulin?
inhibits insulin secretion
3 stimulants which cause insulin secretion?
vagal stimulation, B2 adrenergic stimulation, cholinergic drugs
Some causes of acute pancreatitis (8)?
alcohol, trauma, ulcerative penetration from adjacent structures (duodenum), infection, biliary tract disease, metabolic disorders (hyperlipidemia, hypercalcemia), drugs, surgery
4 drugs which cause acute pancreatitis?
corticosteroids, furosemide, estrogens, thiazide diuretics
2 surgeries which can cause post op pancreatitis?
mobilization of abdominal viscera, cardiopulmonary bypass
First symptom of pancreatitis? And describe it?
pain; localized, radiating, dull, severe; mid epigastric to periumbilical and may be worse when supine
Other symptoms of acute pancreatitis?
N/V, abdominal distention, fever, hypotension, ARF, hypocalcemia with EKG changes (prolonged QT)
How does pancreatitis induce autodigestion?
edema, hemorrhage, necrosis of pancreas
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
Common causes of chronic pancreatitis (3)?
chronic alcohol, pancreatic trauma at early age, chronic biliary tract disease
Diagnosis triad for chronic pancreatitis?
steatorrhea, pancreatic calcification, diabetes mellitus
2 common characteristics of chronic pancreatitis?
malnourished, male>female
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
What organ commonly becomes diseased in chronic pancreatitis?
liver
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
Chronic pancreatitis patients are at a predisposition for developing?
pericardial and pleural effusions
Why is a pancreatic abscess so bad in chronic pancreatitis?
it can cause severe intraabdominal hemorrhage
What is the surgical therapy for pancreatitis?
drainage of a pseudocyst
When is a surgical drainage of a pseudocyst usually done?
after the cyst matures (usually 6 weeks)
Most common indication for pancreatic surgery?
tumor
2 types of pancreatic tumors requiring surgery?
adenocarcinoma, insulinoma
90% of pancreatic adinocarcinomas are?
ductal
If the patient is jaundiced and needing pancreatic surgery, he or she probably has?
biliary obstruction
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)
A pancreatic tumor is resectable if?
it’s not invading blood vessels or hepatobiliary tree
If a pancreatic tumor is resectable, what is the procedure called to remove it?
pancreaticoduodenectomy
What is an ERCP in relation to pancreas?
can obtain biopsy of carcinoma
This surgery includes excision of the antrum of the stomach with the duodenum, distal bile duct, and pancreatic head, reconstruction with choledochostomy, pancreaticogastrojejunostomy
Whipple
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)
Biliary obstruction occurs with what type of pancreatic tjmor?
adenocarcinoma
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)
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
What syndrome can ZES be a part of?
MEN 1
In ZES can tumors be elsewhere than the pancreas?
yes
ZES is also known as?
gastronoma
Treatment for gastronoma/ZES?
complete pancreatectomy
What is taken out on pancreatectomy?
parts of duodenum, antrum of stomach, gall bladder, common bile duct, complete pancreas and pancreatic duct, hepatojejunostomy, duodenojejunostomy
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
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
Anesthetic plan for pt with pancreatic disease depends on?
health of pt and comorbidities
4 lyte disorders that may be present in pt with pancreatic disease?
hypocalcemia, hypomagnesemia, hypokalemia, hypochloremic metabolic alkalosis
ERCP diagnoses and treats certain problems of?
biliary or pancreatic duct systems
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
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
1 year graft and patient survival rates of pancreas transplant are?
70%; 91%
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
What is the goal for crystalloids in pancreatic transplant pt and why?
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
Airway eval in pancreatic transplant pt- look out for?
increased difficulty in intubation of diabetic patients
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
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)
5 s/s to assess for preop in pancreatic transplant pt?
diarrhea, bloating, hypotension on initiation of dialysis, esophageal dysfunction, dizziness with position change
Easiest way to assess for autonomic neuropathy?
take BP lying down and flat
What’s the functional unit of the liver? And how many of them are there in liver?
hepatic lobule; 50,000-100,000
Blood supply to liver is from what 2 things?
hepatic artery and portal vein
How many mL of blood/min and what % of CO does liver receive?
1500 mL blood/min; 25-30% CO
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
7 functions of the liver?
bile production, protein synthesis, glycogen storage, protein metabolism, insulin clearance, lactate conversion in to glucose, drug metabolism and transformation
Liver is innervated by which nerves?
splanchnic nerves derived from spinal nerves T3-T11
What type of adrenergic receptors are present in hepatic arterial circulation?
alpha and beta
Which adrenergic receptors are in the hepatic/portal vein?
only alpha
Hepatic arterial flow is autoregulated in accordance with?
metabolic demand
Portal blood flow is dependent on?
combined venous outflow from spleen and GI tract
Largest organ and largest gland in human body?
liver
The liver is located in what quadrant and rests just below the?
right upper quadrant; diaphragm
The liver lies to the right of the? And overlies the?
stomach; gallbladder
Hepatic artery carries blood from the?
aorta
Hepatic vein carries blood containing?
digested nutrients from entire GI tract, spleen, and pancreas
The hepatic artery and portal vein subdivide in to? Which supply?
capillaries; lobules of liver
The hepatic lobule is also known as?
acinus
The acinus architecture radiates around?
a single vein which empties in to hepatic veins and then in to vena cava
Oxygen is provided to the liver by?
hepatic artery (1/2) and portal vein (1/2)
Blood flow in the liver flows thru what? and then empties in to what?
sinusoids and then empties in to central vein
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
Which 2 ducts make up the common bile duct?
cystic duct from gall bladder and common hepatic duct
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
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
Bile drains directly in to duodenum via? Or bile can be temporarily stored in _____ via _____?
common bile duct; gall bladder, cystic duct
Common bile duct and pancreatic duct enter the 2nd part of the duodenum together at the?
ampulla vader
Which liver lobe is typically singularily taken from donor?
left
Blood from the gut is cleansed of its colonic bacilli by what cells in the liver?
Kupffer cells (macrophages)
Where do the Kupffer cells lie?
they line the hepatic sinuses
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
The hepatic artery delivers how many mL/min of portal oxygenated blood?
400-500 mL/min
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%
The portal vein collects blood that leaves which organs?
spleen, stomach, SI, LI, gallbladder, and pancreas
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
Why is the liver relatively resistant to hypoxia?
dual blood supply
Cells that line the sinusoids in the liver?
epithelial cells and Kupffer cells
Hepatic veins empty in to what?
inferior vena cava
Range of portal vein pressure?
6-10 mm Hg
The mean pressure in the hepatic artery is similar to?
that in the aorta
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
Portal blood flow is dependent on combined venous blood flow of?
from spleen and GI tract
Do anesthetics alter hepatic integrity?
no
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)
HABR works by?
changes in hepatic artery or portal vein blood flow may not result in an overall change in hepatic blood flow
All intraabdominal organs are drained in to?
superior mesenteric vein and hepatic portal vein
What is gluconeogenesis? What stimulates it?
formation of glucose from noncarb molecules lactate and pyruvate and amino acids; reduction of glycogen stores
During periods of fasting, the liver maintains glucose levels at normal levels by what?
glycogenolysis
What is glycogenolysis and what stimulates it?
process of liberating glucose from glycogen stores found in the liver and skeletal muscle; epinephrine and glucagon
Hypoglycemia occurs in liver patients for what 3 reasons?
derangements in insulin clearance, decrease in glycogen capacities, impairment in gluconeogenesis
With the exception of what, protein synthesis mostly occurs in the liver?
immunoglobulins
What typically happens to plasma oncotic pressure in liver patients?
decreases
Why is there a larger Vd in liver patients?
decreased oncotic pressure result in overextension of interstitial space and 3rd spacing
What does a decreased protein level mean for NDMR?
needs to be increased d/t larger Vd
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
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
How does the liver aid in intestinal digestion?
forming bile and secreting it in to the common bile duct
5 functions of liver?
carb metabolism, protein synthesis, amino acid synthesis, protein metabolism, bile production
What’s the end product of hemoglobin metabolism?
conjugated bilirubin
What continuosly secretes fluid in the liver that contains phospholipids, cholesterol, conjugated bilirubin, bile salts, and others?
hepatocytes
Where is bile stored and concentrated?
gall bladder
What hormone releases bile in to the gallbladder?
CCK
What initiates contraction of the gall bladder and movement of bile via the common bile duct?
presence of fat and protein in the duodenum
Where does the common bile duct merge with the pancreatic duct?
ampulla of vater
How does the ampulla of vater empty in to the duodenum?
sphincter of oddi
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
Impaired bile production or flow may lead to what 3 things?
steathorrhea, vit K deficiency, delayed removal of active drug metabolites
The liver is responsible for producing all clotting factors except?
VIII
5 more functions of the liver?
lipid metabolism, coagulation factor synthesis, insulin clearance, drug metabolism/transformation, bilirubin metabolism
Main site for insulin clearance?
liver
The enzyme systems involved in biotransformation of drugs are located primarily in the ______ and also in the _______?
liver; lung
Bilirubin is a breakdown product of?
heme metabolism
Which bilirubin is toxic in high levels and not soluble in water?
unconjugated
What system is primarily responsible for Phase I reactions?
CYP 450
The type of phase reaction is important for metabolizing many of the anesthetic drugs?
Phase I
One word difference between Phase I and Phase II reaction?
Phase I: functionilization; Phase II: conjugation
Morphine and acetaminophen are metabolized by what phase reaction?
II
What happens in a phase I reaction?
add or exposure a functional group (oxidation, reduction, hydrolysis)
With the exception of a prodrug, what typically happens to pharmacologic activity in a Phase I reaction?
loss of pharmacologic activity
What happens in a Phase II reaction?
Phase I product (substrate) conjugates with a 2nd molecule
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
What % of drugs are manufactured by CYP450?
50%
When 2 drugs are administered and metabolized by the same enzyme system, what happens to the rate of metabolism?
can be increased or decreased
Regarding CYP450, enzyme induction hastens metabolism in coadminstered drugs like?
ketamine, benzos, barbs, ethanol
Regarding CYP450 enzyme induction promotes tolerance to meds like?
sedatives, opioids, steroid muscle relaxants
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
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
5 risk factors for mortality r/t liver disease?
high child-pugh score, ascites, elevated serum creatinine, preop upper GI bleed, high ASA rating
3 types of hepatitis?
acute, chronic, drug induced
3 causes of acute hepatitis?
viral, hepatotoxic substance, adverse drug reaction
2 causes of drug induced hepatitis?
alcohol, acetaminophen
Patients have 1 of 3 syndromes in chronic hepatitis? Which one is the worst?
chronic persistent, chronic lobular, chronic active; chronic active
2 labs which would indicate normal liver function in patient who has been postponed d/t abnormal liver ftn?
LFTs, platelets
2 things which increase morbidity and mortality for liver patients?
acute intoxication and acute viral hepatitis
Alcoholics in DTs have what mortality rate?
50%
5 anesthetic considerations for alcohol in DTs?
decreased anesthetic required, aspiration precautions, platelet aggregation inhibited, brain more sensitive to hypoxia, increased circulating catecholamines
3 lab tests in severe liver disease?
increased PT, decreased albumin, low platelet count
S/s of severe liver disease?
encephalopathy, bleeding diatheses, jaundice, ascites, HD findings
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
Child Turcotte Pugh Score contains what 6 items?
encephalopathy, ascites, bilirubin, albumin, PT, for PBC/PSC
What does portal hypertension interfere with?
liver’s metabolic and synthetic processes
What electrolyte disturbance is common in cirrhosis?
metabolic alkalosis
3 examples of direct liver injury?
alcoholism, viral hepatitis, autoimmune hepatitis
Indirect injury to liver occurs via damage to what?
bile duct
Some causes of indirect injury to the liver?
biliary cirrhosis, sclerosing cholangitis, biliary atresia,
Indirect cause of cirrhosis in infants?
biliary atresia
2 inherited disorders that result in abnormal storage of metals in liver leading to tissue damage and cirrhosis?
Wilson’s disease; hemochromatosis
Disease where patients store too much copper in the liver, brain, kidneys, and corneas of eyes?
Wilson’s disease
Most common cause of portal HTN?
cirrhosis
What 2 factors impact development of portal HTN?
vascular resistance and blood flow
When portal HTN rises above what, varices and ascites can result?
12 mm Hg
Main complication of portal HTN?
esophageal varices
Main complication of portal HTN is _____ and it is caused by _______?
GI hemorrhage; esophageal varices
The response to increased venous pressure regarding the liver is?
development and engorgement of collaterals—> varices
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
9 common s/s cirrhosis?
hepatic encephalopathy, esophageal varices, skin spider angiomas, malnutrition, splenomegaly, periumbilical caput medusa, ascites, hemorrhoids, testicular atrophy
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
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)
4 mechanisms responsible for ascites?
portal HTN, hypoalbuminemia, seepage of protein rich lymphatic fluid, renal Na retention
When is ammonia produced?
when proteins are digested
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
5 risk factors for hepatorenal syndrome?
BP that falls when person rises or suddenly changes position, diuretics, GI bleed, infection, recent paracentesis
What’s the term for nitrogen waste product build up in person with hepatorenal syndrome?
azotemia
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
4 factors which are deficient for clotting in liver disease pt (these were bolded)?
II, VII, IX, X
Why should you be careful with positive pressure ventilation in liver disease pt?
can worsen already poor venous return which decreases CO
Why do you have to be careful with OG/NGT insertion in liver disease pt?
esophageal varices
Most anesthetics do what to hepatic/splanchic blood flow and how does that effect drugs?
decrease; may cause drugs to be metabolized slower
Drugs that induce enzymatic pathways will be metabolized at what rate? How do you adjust the drug?
more quickly; give more
Drugs that inhibit enzymatic pathways will metabolize at what rate? What do you have to do to the drug?
more slowly; less drug
Drugs that use similar pathways may what to each other?
inhibit or enhance
Deficient plasma cholinesterase may prolong effects of what 3 drugs?s
suxxs, esmolol, ester local anesthetics
What should you do to the NMDR dose in liver disease pts and why?
increase bc larger Vd
This anesthetic gas causes the greatest reduction in hepatic blood flow?
halothane
How does halothane cause a reduction in hepatic blood flow?
hepatocyte hypoperfusion, hypersensitive immune response
Halothane is more likely to occur with what exposure?
1st, 2nd, 3rd
Why do you want to avoid sphincter of oddi spasms in liver disease pt?
increase in biliary pressure
Some meds that cause sphincter of oddi spasms?
morphine>meperedine>butorphanol>nalbuphine
Preferred narc to not induce sphincter of oddi spasms?
fentanyl
3 other causes of sphincter of Oddi spasm?
surgical manipulation, cold irrigation, contrast dye
3 meds to give to liver disease pt w ascites and edema?
albumin, mannitol, K sparing diuretics
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
Acceptable hematocrit in liver disease pt is?
30%
Acceptable platelet count in liver disease pt before surgery?
> 100,000
What 3 blood products should be available besides PRBC for liver disease pt before surgery to correct coagulopathies?
cryo, FFP, platelets
What liver disease characteristic makes the need for asceptic technique mandatory?
leukopenia
Is regional anesthesia ok in liver disease pt?
yes if no coagulopathies
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
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
Is suxxs acceptable in liver failure?
yes, just know it may be prolonged
3 types of meds that are highly protein bound and should have the dosage reduced in liver disease pts?
benzos, barbs, some opiates
Good choice for paralytic in liver disease pt?
cis
Volatile agent of choice in liver disease pt?
isoflurane; no sevo bc Fl ion production
Why is fentanyl a good opioid in liver disease pt?
least effect on hepatic blood flow, O2 supply, O2 consumption
Other good opioids besides fent in liver disease pt?
sufenta, alfenta, remifent
3 things to AVOID in liver disease pt bc they reduce hepatic blood flow?
hypotension, excessive sympathetic activation, high mean airway pressures
How do vasopressin and somatostatin treat esophageal varices?
they’re splanchic vasoconstrictors
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
Treatment of esophageal varices that compresses the varices?
triple lumen sengstaken blakemore tube
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
Dose of ocreotide?
50 mcg/hr infusion
Whats the rebleed rate on sclerotherapy for esophageal varices, and it is done under what type of anesthesia?
60%; conscious sedation
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)
What anesthesia is TIPS done under?
conscious with local
How are the anesthetic considerations for TIPs patient different from liver disease pt anesthetic considerations?
they’re the same
What’s the EBL in TIPS procedure?
potential for large
Monitors during TIPS?
a line, CVP, PA cath, UO
Target PaCO2 in TIPS pt and why?
> or = 40 to maintain portal blood flow
Is N2O ok in TIPS pt?
no
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
Complications of TIPS?
liver laceration, massive hemorrhage, gall bladder perf, renal failure from contrast dye
Key for liver transplantation surgery?
immunosuppressive therapy such as cyclosporine and tacrolimus
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
What are 2 risks/complications during liver transplant when perfusion of emplaced graft?
hyperkalemia, VAE
Anticipate what type of blood loss in liver transplant?
large; have platelets, cryo, FFP
What type of monitoring do you want for liver transplant pt?
invasive monitoring; large bore IVs, possibly 8.5 F AC RIC line
2 lyte abnormalities for liver transplant?
hyperk, hypoca
What antiHTN agents should you avoid in transplant pts?
long acting
What is specific about HD monitoring in liver transplant pt?
2 sites are often used for arterial monitoring
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
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
Some labs that are indicated for coagulation profiles in liver transplant patient?
PTT, PT, fibrinogen levels, degradation levels, platelet count
What lab tests allows for factor specific determinations of abnormalities and therapeutic responses
factor activity
This test allows bedside eval of coagulation with patterns typical of factor and platelet deficiency and fibrinolysis
TEG
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
How much blood product should be available for liver transplant?
10-20 U PRBC, FFP, plasma
What is commonly used in liver transplant when cancer or infection is not suspected and is r/t preventing bleeding?
cell savage
Negative about cell salvage?
large volumes of processed cells may dilute platelets and coagulation factors; effect on fibrinolysis is controversial
What is it called when flow from femoral and portal vein to axillary or IJ maintains venous return during caval interruption?
venovenous bypass
What % of liver can be resected?
80-85%
What’s the blood loss anticipated in hepatic surgery?
large
What type of CVP may be desirable in liver resection surgery to reduce the amt of bleeding?
lower
3 indications for hepatic surgery?
repair of lacerations, drainage of abscess, and resections for tumors
Some antifibrinolytics to be used during hepatic surgery?
amicar; aprotinin
What type of sugar levels would you expect in liver surgery pt?
hypoglycemia
Blood flow to the spleen?
300 mL/min
3 zones of the spleen?
white pulp, red pulp, marginal zone
Where does the spleen lie?
9th-11th rib, between the fundus of the stomach and the diaphragm
2 surfaces of the spleen?
diaphragmatic and visceral
Part of spleen which consists of splenic sinusoids (large thin walled vessels)
red pulp
Part of spleen which contains the end arterial branches of central arteries and contain lymphocytes, macrophages, and plasma cells
white pulp
Zone of spleen which contains the vascular space with the white pulp and red pulp?
marginal zone
What;s the nerve supply to the spleen?
sympathetic fibers are derived from the celiac plexus
The spleen is made up of what 4 components?
red pulp, white pulp, supporting tissue, vascular system
This part of the spleen is fibroelastic and forms the capsule, coarse trabeculae, and a fine reticulum?
supporting tissue
The white pulp/lymph nodules are arranged around an eccentric arteriole called?
Malpigian corpuscle
The lymphocytes in the spleen are freely transformed in to?
plasma cells, which can produce large amounts of antibodies and immunoglobulins
Red pulp in the spleen is where?
in between the sinusoids
3 types of cell population in spleen?
lymphocytes, fixed and free macrophages, blood cells
3 physiologic functions of the spleen?
hematopoiesis in fetus, blood filtering, immune processing of blood borne foreign antigens,
One of spleens most important functions?
phagocytosis
Phagocytes in the spleen remove what?
debris, old RBCs and other cells, and microorganisms
Phagocytosis in spleen initiates what response (immune related)?
humoral and cellular
What % of RBCs are present in the spleen?
8%
Splenectomy is treatment of what 5 things?
ITP, TTP, hodgkin’s disease, lymphoma, some leukemias, hemolytic anemia, hypersplenism, spheroctyosis, sickle cell disease, traumatic injury
This disease causes extensive microscopic clots to form in the small blood vessels thus causing organ damage?
TTP
A bleeding condition in which the blot doesn’t clot as it should and a splenectomy is treatment?
ITP
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
Is there a lot of blood loss anticipated in splenectomy?
yes
Where are 2/3 of carcinoid tumors?
GI tract
Carncinoid tumors are composed of what cells?
enterochromaffin cells (Kupffer cells)
Some bioactive substances secreted by carcinoid tumors?
serotonin, histamine, kinin peptides, dopamine, substance P, gastrin, somatostatin, calcitonin, ACTH and others
Non GI sites of carcinoid tumor locations?
thymus, lungs, pancreas, liver
2 factors which enhance release of carcinoid syndrome?
direct stimulation, beta adrenergic stimulation
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
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)
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
4 s/s from elevated serotonin?
bronchospasm, hyperglycemia, vomiting, prolonged drowsiness after emergence from anesthesia
Histamine can produce what 2 things in carcinoid syndrome pts?
bronchospasm and flushing
4 s/s from bradykinin?
bronchospasm, flushing, hypotension (d/t vasomotor relaxation),
2 substances responsible for cutaneous flushing in carcinoid syndrome pt?
kinines, histamine
3 substances responsible for bronchospasm in carcinoid syndrome pt?
serotonin, bradykinin, substance P
4 substances responsible for profuse diarrhea in carcinoid syndrome?
serotonin, prostaglandins, substance E and F
3 effects carcinoid syndrome produces on heart/heart disease?
tricuspid regurg, pulmonic stenosis, SVTs
Bronchoconstriction in carcinoid syndrome pt is produced by what 3 things?
serotonin, bradykinin, substance P
Why would abdominal pain occur in carcinoid syndrome pt?
small bowel obstruction
Some other systemic manifestations of carcinoid syndrome?
hepatomegaly, hyperglycemia, hypoalbuminemia, right sided HF
Why would a carcinoid pt have skin lesions?
niacine deficiency
What prevents left sided involvement in carcinoid syndrome pt?
lung metabolism of serotonin
Diagnosis of carcinoid syndrome?
serotonin metabolites in the urine, elevated plasma levels of chromogranin A
Treatment of carcinoid syndrome?
surgical removal or management of symptoms
Some labs to get preop in carcinoid pt?
CBC, lytes, glucose
What meds can minimize effects of histamine in carcinoid pt?
H1 and H2 blockers
Most often used anesthesia for carcinoid pt?
general but all can be used
Serotonin antagonists used for carcinoid syndrome?
ocreotide and somatostatin
Dose of ocretotide and 1/2 life?
100 mcg SQ 2-3 times a day; 100 min
1/2 life of somatostatin?
2-3 min
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
Good sedative meds used for induction in carcinoind pt?
etomidate, propofol
Good muscle relaxants in carcinoid pt?
vec, roc, cis
4 narcs good in carcinoid pt?
fent, remi, alfenta, sufenta
3 gasses used in carcinoid pt?
sevo, iso, des
Which reversal agents are good in carcinoid pt?
neostigmine, edrophonium
What do you have to avoid in carcinoid syndrome pt?
anything that could cause vasoactive release of substances from tumor
Avoid what 3 meds in carcinoid pt d/t kallikrinin release?
ketamine, epi, ephedrine
How should hypotension be treated in carcinoid pt?
alpha adrenergic like phenyl
what type of anesthesia does carcinoid pt need?
DEEP!
What may inhibit kallkreins and reverse carcinoid induced bronchospasm and hypotension?
aprotinin
