Ascites

Question 1

What contributes to formation of ascites?

Answer 1

portal HTN
Hypoalbuminemia
Sodium and water retention

Question 2

Specific mechanism of ascites:

Answer 2

Splanchnic arterial vasodilatation occurs secondary to production of vasodilatory mediators in setting of liver failure-in order to maintain systemic perfusion, renal sodium and water retention increase (ascites)

Question 3

Common treatment for patients with ascites:

Answer 3

Decrease sodium intake 
Diuretic therapy (spironolactone-aldosterone antagonist)

Question 4

When you do large volume paracentesis, or when the belly is opened in a patient with ascites-what are you expecting:

Answer 4

circulatory collapse-re-equilibraion occurs 6-8 hours after the removal of large amounts of fluid

Question 5

Pre-operative considerations in patients with ascites:

Answer 5

Full H&P, history of vatical hemorrhage? renal dysfunction? get coags-if prolonged PT time, then give vitamin K, what are there platelets? Get electrolytes and watch for signs of encephalopathy

Question 6

What are your goals of care in ascites patients? What do you want to consider pre-op?

Answer 6

maximize hepatic oxygen delivery, prevent and treat associated complications including-encephalopathy, cerebral edema, coagulopathy, hemorrhage

Consider draining ascites pre-op

Question 7

Intra-op monitors in ascites patients? How are you inducing?

Answer 7

Standard ASA monitors with consideration for a line (frequent blood draws and expectation of fluid shifts) and central line (KIM-pts who are coagulaopathic may have problems with this),
FOLEY
RSI-kim that patient might be intravascularly depleted

Question 8

Muscle relaxants in ascites: What can you and can’t you use?

Answer 8

Sux is acceptable, but keep in mind that liver disease may decrease plasma cholinesterase activity and prolong the duration of action
Cis and roc may be beneficial so that you don’t have to have issues with hepatic metabolism