Anesthesia for hepatobiliary and pancreatic surgery

Question 1

What is a mesocaval shunt?

Answer 1

portosystemic shunt btw superior mesenteric vein and IVC to reduce portal hypertension

Question 2

How does portal HTN affect systemic circulation?

Answer 2

Hyperdynamic= low SVR and high CO

Question 3

What are the clinical manifestations of portal hypertension?

Answer 3

Increased resistance of flow in liver and icrease in splancnic arterial flow
Colateral chanels-varices-attempt to circumvent the hepatic obstruction.
Back pressure in portal system causes splenomegaly and is partly responsible for ascites
GI Bleeding- bleeding of varices-particularly from esophagus is ominous-portal HTN is severe

Question 4

What is a TIPS

Answer 4

Transjugular intrahepatic portosystemic shunt

decompress the portal circulation as a bridge to liver transplant. Performed under GA in IR

Question 5

Which hemodynamic change related to hepatic failure is most likely present in a pt presenting for mesocaval shunt? bradycardia, CHF, High CO, High SVR, tricuspid regurge?

Answer 5

HIgh CO

would have low SVR

Question 6

What is hepatic encephalopathy?

Answer 6

Mental confusion or obtundation
Asterixis - flapping motion of hands at wrist caused by loss of extensor tone
Fetor hepaticus–fruity odor to breath
preoperative encephalopaty -up to 80% risk of mortality

Question 7

What are the causes of encephalopaty?

Answer 7

Cerebral intoxication caused by intestinal contents that have not been metabolized by the liver
protein breadown products from GI bacteria
***Ammonia!–NH3 normally converted to urea by liver is one of the toxic substances believed to interfere with brain metabolism

Question 8

What is the treatment of encephalopathy?

Answer 8

protein restriction 
abx-gut bacteria
reduce diuretic therapy
tx hypokalemia
restrict sedatives
tranquilizers

Question 9

Which volatile anesthetic is best for sx in pts with hepatocellular disease

Answer 9

level of metabolism

halothane (20%)>Sevoflurane (5%)>Isoflurane (0.2%)>Desflurane (0.1)> nitrous

Question 10

Severe liver failure is associated with what serious periopertive problem?

Answer 10

caugulopathy

Question 11

How does cogulation appear with chronic liver disease?

Answer 11

platelet count ok, but poor platelet count.

Check bleeding time test–normal is 3-10

Question 12

What is normal PT?

Answer 12

10-15 sec

Question 13

What is normal PTT?

Answer 13

25-35

Question 14

How do you treat coagulopathy in pts with cronic liver disease?

Answer 14

FFP is the mainstay

Cryo may also be requite to bring PT to within 3 seconds of normal preoperatively

Question 15

Which lab test is a good indication of liver disease?

Answer 15

PT (also useful for vit k deficiencies)

Question 16

What are liver disease complications, S and S?

Answer 16

ascites
coagulopathy
encephalopathy
Gi bleeding 
Jaundice

Question 17

Hepatic blood flow and oxygen supply to liver is…

Answer 17

10-15% of blood volume (70% venous)

total hepatic blood flow 1200-1400 ml/min-25% of CO

Question 18

what is most serious problem associated with massive blood transfusion?

Answer 18

hypocalcemia.
citrate binds calcium
may lead to cardiac arrest.

Question 19

what is normal fibrinogen?

Answer 19

200-400
hypofibrinogenemia is earliest coag disturbance seen in massively transfused pts
less than 100 is asssociated with coagulopathy