Hepatic and Renal Flashcards
Hepatic Blood Flow
20% of CO
Hepatic Blood Flow: Intrinsic Controls
- HABR (hepatic arterial buffer response)
- Metabolic
- Autoregulation
Hepatic Blood Flow: Extrinsic Controls
- Neural
- Humoral
What is HABR?
Hepatic Arterial Buffer Response:
The hepatic arterial buffer response (HABR) is a self-regulating mechanism that helps maintain hepatic perfusion during times of reduced portal venous blood flow, such as during acute occlusion or in cirrhosis
What 4 things does the liver metabolize?
Proteins
Carbohydrates
Lipids
Bile
What does the liver make?
Coagulation factors
Proteins for coagulation
List some protein regulators in coagulation
Protein S
Protein C
Protein Z
Plasminogen Activator Inhibitor
Antithrombin III
How much of heme produciton is done by the liver?
20%
Where is Bilirubin, Angiotensinogen, and Thrombopoietin made?
Liver
How does the liver and thyroid interact?
The liver activates T4 to T3
How do the liver and kidneys interact?
Inactivates aldosterone and ADH
How does the liver and pancreas interact?
Inactivates insulin
What are kupffer cells?
Liver cells that filter toxins and contaminates from splanchnic blood
Hepatic Drug Metabolism: Phases
- Phase 1: CYP increases drug polarity
- Phase 2: conjugating drugs with H2O soluable substrate
- Phase 3: excrete into bile
Liver Function Tests
SLAAPS
Serum Albumin
LDH
ALT
AST
PT
Serum Bilirubin
Normal Albumin
3.5-5.5 g/dL
Normal Prothrombin Time
12-14secs
Normal Bilirubin
0.2-1.1 mg/dL
Which inhaled agent is the worse for hepatic blood flow?
Halothane
Which inhaled agent is associated with Hepatitis?
Halothane
What is ESLD?
End Stage Liver Disease
ESLD: CNS complications
Hepatic Encepalopathy
ESLD: Cardiovascular complications
Hyperdynamic State
Cardiomyopathy
Altered Blood Flow
Portal Hypertension
ESLD: Pulmonary complications
Hypoxemia
Portopulmoary Syndrome
Hepatorpulmonary Syndrome
ESLD: Renal complications
Hepatorenal Syndrome
Edema
Ascities
ESLD: Hematological complications
Coagulopathy / Hypercoagulable
Thrombocytopenia
ESLD: Endocrine complications
Abnormal glucose use
ESLD: GI complications
Esophageal varcies
Hepatic Scoring: Child-Pugh
5-6 = Class A
7-9 = Class B
10-15 = Class C
Lower score the better
Hepatic Scoring: MELD
Model for End-Stage Liver Disease
Lower score = lower % of mortality
Anything over 40 is 71%
Predictive 3 month mortality from Liver Dx
A few common hepatic issues
VICED-F
Variable drug metabolism
Inability to ventilate (Pulmonary Portal Syndrome)
Coagulopathy
Encephalopathy
Difficult glucose control
Full Stomach
What is a TIPS
Transjugular Intrahepatic Portosystemic Shunt
Shut portal vein to hepatic vein to bypass damaged liver and reduce portal hypertension
Which liver reseciton usually bleeds more, wedge or segment?
Wedge
What is mugging?
When the liver is manipulated and the the IVC gets occluded
What is hemodilution?
Pull off some blood
Give same volume back as crystalloid
This keeps the body volume the same while diluting the blood
Give the pulled off blood back after surgery
They do this to reduce hemoglobin losses from blood loss
What is the Pringle Maneuver
Clamp and obliterate all blood flow to the liver
What is a CPDA bag?
Blood bag predosed with an anti-coagulant for a specific volume of blood
Citrate Phosphate Dextrose Adenine
What needs to be put on a CPDA blood bag?
Date
Time
Initials
Patient Sticker
What time frame do we need to give the patients blood back?
8 hours
Porto-Pulmonary Syndrome
AKA Portopulmonary hypertension
the coexistence of portal and pulmonary hypertension
Porto-Renal Syndrome
(Not an issue with renal function)
Dx liver = portal HTN
Cascades to splanchnic vasodilation
RAAS system compensates
Increased renal artery constriction causes ischemia and decreased renal function
Renal autoregulation?
80-180mmHg
Urine Output values
Anuric = 0 mL/hr
Oliguric = <15 mL/hr
Nonoliguric = 15-80 mL/hr
Polyureic = >80 mL/hr
Perioperative oliguria?
< 0.5 mL/kg/hr
BUN
Blood Urea Nitrogen:
byproduct of ammnia metabolism
BUN levels
5-10 mg/dL
BUN:Cr ratio
> than 20:1 = prerenal dx
Renal function indicator
GFR: 125 mL/min
Renal function below 10%
ESRD
Creatine value
0.5-1.0 mg/dL
Doubling of Creatine means what
Reduction of GFR by 50%
Renal vasoconstriction: Salt retention
Decrease in:
RBF
GFR
Urine Flow
Na Excretion
Renal vasodialtion: Salt Excretion
Increase in:
RBF
GFR
Urine Flow
Na Excretion
Name some renal vasoconstrictors
- RAAS
- Aldosterone
- ADH
Name some renal vasodilators
Prostaglandins
Kinins
ANP
Clinical signs of renal failure (HAHA-HP)
- Hypervolemia
- Acidotic
- Hyperkalemia
- Anemia
- HTN
- Pulmonary edema
Drug metabolism in renal dx
- Morphine
- Meperidine
- Sevo / Compound A
What is propofol infusion syndrome?
Green Urine due to 4mg/kg/hr for more than 48 hours
Non depole muscle relaxers in renal dx patients?
Longer acting due to partial clearance in kidney.
Succ’s in renal dx?
cleared independently of renal activity
Two types of renal replacement therapy?
Hemodiaylsis
Peritoneal dialysis
Complications of hemodialysis?
Hypovolemia induced hypotension
hypopnea
What is a CRRT machine?
Continuous Renal Replacement Therapy
Used in the ICU for hemodialysis
processes blood much slower so no hypovelmia
TURP
Transurethral Resection of Prostate
TURP syndrome
The absorption of large amounts of fluid (2 L or more) results in a constellation of symptoms and signs
TURP syndrome treatment
Fluid restrictions (fluid overloaded)
Lasix
Hypertonic Saline 3% (last resort)
What is at a higher risk for blood loss, partial or radical nephrectomy?
Partial
Open verse robotic prostate?
Open = bloody as hell
Robotic = the way to go
