Hepatic Failure Flashcards
What is ‘acute fatty liver of pregnancy’?
Acute fatty liver of pregnancy is the accumulation of fat within
the hepatocytes. It typically occurs during the third trimester of
pregnancy. About half of the patients with this condition
exhibits signs of HELLP syndrome (hemolysis, elevated liver
enzymes, and low platelet count).
Chestnut DH, Polley LS, Tsen LC, Wong CA. Chestnut’s
Obstetric Anesthesia. Philadelphia, PA: Mosby Elsevier; 2009:
1015
How does end-stage liver disease affect the
systemic vascular resistance, cardiac output, and
mixed-venous oxygen saturation?
End stage liver disease is generally associated with a very low
SVR, and an increased cardiac output and mixed venous
oxygen saturation.
Butterworth JF, Mackey DC, Wasnick JD. Morgan & Mikhail’s
Clinical Anesthesiology. 5th ed. New York, NY: McGraw-Hill;
2013: 712.
What are the symptoms of acute hepatic failure?
Jaundice, malnutrition, hypoglycemia, coagulopathy,
hypoalbuminemia, depressed immune function, altered
mentation, prolonged prothrombin time, respiratory alkalosis,
and renal impairment.
Longnecker DE, Newman MF, Brown DL, Zapol WM.
Anesthesiology. 2nd ed. New York: McGraw-Hill; 2012: 192-
193.
What does the term ‘fulminant hepatic failure’ mean?
Fulminant hepatic failure is defined as liver failure with
encephalopathy that develops within 2-8 weeks following the
onset of illness in a patient with no previous history of liver
disease.
Longnecker DE, Newman MF, Brown DL, Zapol WM.
Anesthesiology. 2nd ed. New York: McGraw-Hill; 2012: 192.
What laboratory findings are consistent with the
development of acute liver failure?
Elevated aminotransferase levels, prolonged prothrombin time,
hypoglycemia, hyponatremia, hypokalemia, hyperinsulinemia
and lactic acidosis, are all consistent with acute liver failure.
Respiratory alkalosis may appear due to hyperventilation.
Longnecker DE, Newman MF, Brown DL, Zapol WM.
Anesthesiology. 2nd ed. New York: McGraw-Hill; 2012: 193.
How is systemic vascular resistance affected by
acute liver failure?
It is usually decreased, resulting in hypotension. Patients who
developed cerebral edema due to acute liver failure, however,
may exhibit hypertension and bradycardia.
Longnecker DE, Newman MF, Brown DL, Zapol WM.
Anesthesiology. 2nd ed. New York: McGraw-Hill; 2012: 192-
193.
What are the characteristics of hepatorenal
syndrome?
Hepatorenal syndrome is oliguric renal failure that can occur
with acute liver failure.
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Nagelhout JJ, Plaus KL. Nurse Anesthesia. 5th ed. St. Louis,
MO: Elsevier Saunders Company; 2014: 770-772.
What are some factors that could precipitate hepatic
encephalopathy in patients with cirrhosis?
Gastrointestinal hemorrhage, diuretics, azotemia, constipation,
increased dietary protein intake, and hypokalemia can all
produce an increase in serum ammonia levels which can
precipitate hepatic encephalopathy in patients with cirrhosis.
Barash PG, Cullen BF, Stoelting RK, Cahalan MK, Stock MC,
Ortega R. Clinical Anesthesia. 7th ed. Philadelphia, PA:
Lippincott Williams and Wilkins; 2013: 1311.
What is the treatment for acute fatty liver of
pregnancy?
The treatment for acute fatty liver of pregnancy is immediate
termination of the pregnancy. If left untreated, this condition
progresses to acute liver failure and death.
Chestnut DH, Polley LS, Tsen LC, Wong CA. Chestnut’s
Obstetric Anesthesia. Philadelphia, PA: Mosby Elsevier; 2009:
1015-1016.
How does biliary obstruction affect coagulation?
The gastrointestinal absorption of vitamin K relies on the
secretion of biliary enzymes. As vitamin K levels decrease, the
clotting factors reliant on vitamin K for their synthesis (II, VII, IX,
and X) are impaired, resulting in a decreased coagulability.
Barash PG, Cullen BF, Stoelting RK, Cahalan MK, Stock MC,
Ortega R. Clinical Anesthesia. 7th ed. Philadelphia, PA:
Lippincott Williams and Wilkins; 2013: 1304
What are the typical clinical findings in a patient with
cirrhosis?
Typical findings in a patient with cirrhosis include: right-to-left
shunting, hypoxemia, hyperventilation, increased right atrial
filling pressures, decreased systemic vascular resistance,
increased cardiac output, decreased blood viscosity due to
anemia, hyponatremia, hypokalemia, hypomagnesemia,
hypoalbuminemia, and hypoglycemia.
Butterworth JF, Mackey DC, Wasnick JD. Morgan & Mikhail’s
Clinical Anesthesiology. 5th ed. New York, NY: McGraw-Hill;
2013: 712.
What are the presenting symptoms of acute fatty
liver of pregnancy?
Patients exhibit viral-like symptoms (malaise, nausea, and
vomiting) and right upper quadrant pain. Jaundice develops
within one to two weeks.
Chestnut DH, Polley LS, Tsen LC, Wong CA. Chestnut’s
Obstetric Anesthesia. Philadelphia, PA: Mosby Elsevier; 2009:
1015-1016.
What patients have the highest incidence of
nonalcoholic fatty liver disease?
It is more common in males and the incidence increases with
age. The incidence is highest in Hispanics (45%).
Barash PG, Cullen BF, Stoelting RK, Cahalan MK, Stock MC,
Ortega R. Clinical Anesthesia. 7th ed. Philadelphia, PA:
Lippincott Williams and Wilkins; 2013: 1314.
What are the treatment options for nonalcoholic fatty
liver disease?
Weight loss and bariatric surgery weight loss can significantly
improve and even cure this condition.
Hines RL, Marschall KE. Anesthesia & Co-Existing Diseases.
6th ed. Philadelphia, PA: Elsevier-Saunders; 2012: 320-321
What are the signs and symptoms of alcoholic
hepatitis?
Alcoholic hepatitis is characterized by jaundice and virus-like
symptoms. The AST and ALT may be elevated as much as ten
times normal. The AST level is typically much higher than the
ALT level.
Barash PG, Cullen BF, Stoelting RK, Cahalan MK, Stock MC,
Ortega R. Clinical Anesthesia. 7th ed. Philadelphia, PA:
Lippincott Williams and Wilkins; 2013: 1301.
What are the treatment options for alcoholic
hepatitis?
Abstinence from alcohol, bed rest, corticosteroids, and a high
protein diet if encephalopathy is not present.
Barash PG, Cullen BF, Stoelting RK, Cahalan MK, Stock MC,
Ortega R. Clinical Anesthesia. 7th ed. Philadelphia, PA:
Lippincott Williams and Wilkins; 2013: 1301.
How does a history of chronic alcohol abuse affect
perioperative morbidity rates?
A history of chronic alcohol abuse is associated with a 200-
300% increase in the risk of perioperative morbidity.
Barash PG, Cullen BF, Stoelting RK, Cahalan MK, Stock MC,
Ortega R. Clinical Anesthesia. 7th ed. Philadelphia, PA:
Lippincott Williams and Wilkins; 2013: 1315-1316.
What is portal hypertension?
Portal hypertension is a hallmark of end-stage cirrhosis. It is
characterized by an increase in the portal venous pressure due
to an increased vascular resistance in the hepatic sinusoids. It
leads to the development of an extensive collateral circulation
network, esophageal varices, ascites, altered drug metabolism,
and an increased risk for infection.
Barash PG, Cullen BF, Stoelting RK, Cahalan MK, Stock MC,
Ortega R. Clinical Anesthesia. 7th ed. Philadelphia, PA:
Lippincott Williams and Wilkins; 2013: 1304.
What are the clinical signs of cirrhosis?
Hepatosplenomegaly, ascites, jaundice, spider nevi, and
encephalopathy.
Hines RL, Marschall KE. Anesthesia & Co-Existing Diseases.
6th ed. Philadelphia, PA: Elsevier-Saunders; 2012: 279.
What are the two most common causes of chronic
hepatitis?
Alcohol abuse is the most common followed by chronic hepatitis
C infection
Hines RL, Marschall KE. Anesthesia & Co-Existing Diseases.
6th ed. Philadelphia, PA: Elsevier-Saunders; 2012: 279.
What is nonalcoholic fatty liver disease?
Nonalcoholic fatty liver disease is fat accumulation in the liver
that is estimated to be present in 30% of American adults. It is
characterized by lobular inflammation and perisinusoidal
fibrosis. Most patients are asymptomatic, but the condition can
lead to cirrhosis.
Barash PG, Cullen BF, Stoelting RK, Cahalan MK, Stock MC,
Ortega R. Clinical Anesthesia. 7th ed. Philadelphia, PA:
Lippincott Williams and Wilkins; 2013: 1314.
What clotting factors are synthesized in the liver?
All clotting factors are synthesized in the liver with the exception
of von Willebrand factor, tissue thromboplastin, and calcium.
Barash PG, Cullen BF, Stoelting RK, Cahalan MK, Stock MC,
Ortega R. Clinical Anesthesia. 7th ed. Philadelphia, PA:
Lippincott Williams and Wilkins; 2013: 1304.
How is the blood volume affected by cirrhosis?
Patients with cirrhosis have an elevated total blood volume, but
much of it is sequestered in the splanchnic bed, leaving the
volume in the central circulation lower than normal.
Barash PG, Cullen BF, Stoelting RK, Cahalan MK, Stock MC,
Ortega R. Clinical Anesthesia. 7th ed. Philadelphia, PA:
Lippincott Williams and Wilkins; 2013: 1305.
How does cirrhosis result in thrombocytopenia?
Cirrhosis results in splenomegaly. The enlarged spleen can
sequester as much as 90% of the circulating platelets. Cirrhotic
patients also exhibit a decreased synthesis of platelets due to
decreased synthesis of thrombopoetin. Bone marrow
suppression by ethanol also contributes to the development of
thrombocytopenia.
Barash PG, Cullen BF, Stoelting RK, Cahalan MK, Stock MC,
Ortega R. Clinical Anesthesia. 7th ed. Philadelphia, PA:
Lippincott Williams and Wilkins; 2013: 1305.
