GI

Question 1

Is a small bowel obstruction or large bowel obstruction more emergent?

Answer 1

SBOs have a greater propensity to strangulate

Question 2

How much fluid is normally secreted into the upper GI tract?

Answer 2

7-9 L daily

Question 3

Describe usual recovery from a post-operative ileus.

Answer 3

small bowel: 24 hours

gastric motility: 24-48 hours

colon: 3-5 days

Question 4

What are the risks of cricoid pressure?

Answer 4

lateral displacement of the esophagus in >50% of cases

reflex relaxation of the LES

obscured view of larynx

Question 5

What are the down sides to leaving an NG tube in place during induction?

Answer 5

no assurance of an empty stomach

mechanical incompetence of the LES

Question 6

What electrolyte abnormalities contribute to a prolonged post-op ileus?

Answer 6

hyponatremia

hypokalemia

Question 7

What are the hemodynamics associated with ESLD?

Answer 7

tachycardia

elevated CO

low SVR

low MAP

Question 8

Why do patients with ESLD have hyponatremia?

Answer 8

increased secretion of ADH

Question 9

What causes hepatic encephalopathy?

Answer 9

Possibly ammonia, but levels do not correlate with severity

Question 10

What coagulation abnormalities in ESLD promote bleeding?

Answer 10

reduced synthesis of coagulation factors

thrombocytopenia

elevated tPA

Question 11

What coagulation abnormalities in ESLD promote clotting?

Answer 11

increased vWF and factor VIII

decreased proteins C and S

decreased ADAMTS-13

Question 12

How is fibrinogen affected by ESLD?

Answer 12

higher levels but dysfunctional

Question 13

Why are pateints with ESLD thrombocytopenic?

Answer 13

sequestration in the spleen

impaired hepatic synthesis of thrombopoietin

consumption during DIC

Question 14

Apart from primary pulmonary disease, what causes hypoxia with ESLD?

Answer 14

atelectasis from compressive ascites

hepatic hydrothorax

hepatopulmonary syndrome

Question 15

What are the consideration during induction for liver transplant?

Answer 15

RSI due to delayed gastric emptying

reduced FRC due to ascites

Question 16

What is the pre-anhepatic phase of liver transplant? What happens during this phase?

Answer 16

induction to hepatic artery clamping

mobilization of the liver, isolation of the vasculature, division of the bile duct

Question 17

What is the anhepatic phase of liver transplant? What happens?

Answer 17

from removal of the diseased liver to reperfusion of the donor liver

anastomoses in this order: vena cava, portal vein, hepatic artery, bile duct

Question 18

What physiologic derangements occur during the anhepatic phase?

Answer 18

acidosis: no clearance of lactic acid
hypocalcemia: no clearance of citrate
hyperkalemia: no hepatic uptake and acidosis
hypoglycemia: no gluconeogenesis

Question 19

What are the benefits of venovenous bypass during liver transplant?

Answer 19

decrease portal circulation and gut congestion (better surgical visualization)

maintain preload during IVC clamping

maintain normothermia

Question 20

What is the major benefit of a cavo-caval “piggy back” anastomosis during liver transplant?

Answer 20

better hemodynamic stability as IVC flow and preload can be maintained

Question 21

Unclamping of which vessel is associated with hemodynamic instability during liver transplant?

Answer 21

portal vein

Question 22

What is the neohepatic phase of liver transplant? What happens?

Answer 22

following reperfusion of the donor liver

biliary reconstruction

Question 23

What is the lethal triad of massive transfusion?

Answer 23

acidosis

coagulopathy

hypothermia

Question 24

What are the indications for CRRT during liver transplant?

Answer 24

pre-operative dialysis

AKI

Question 25

What are early signs of good graft function during liver transplant?

Answer 25

resolution of hypocalcemia

resolution of hyperkalemia

hyperglycemia resistant to insulin