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Anesthesia Practice T3 > Hepatic Lecture > Flashcards

Hepatic Lecture Flashcards

1
Q

the liver is the largest organ, making up what % of body weight in adults and neonates?

A

2% adults (1.5 kg)

5% neonates

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2
Q

the liver has __ segments

A

8

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3
Q

the liver has __ lobes

A

2

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4
Q

the functional units of the liver are what? (2)

A

1) lobule

2) acinus

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5
Q

what % of the total blood volume goes to the liver?

A

10-15%

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6
Q

the liver holds ___ ml of blood per 100gm of tissue

A

25-30 ml

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7
Q

the liver holds blood that is ___% venous blood

A

70% venous blood

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8
Q

hepatic blood flow is _____ ml/min

A

1200-1400 ml/min

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9
Q

hepatic blood flow receives ___% cardiac output

A

25%

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10
Q

where is there more blood flow; the portal vein or the hepatic artery?

A 
portal vein (70-80%)
over 
hepatic artery (20-30%)
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11
Q

what is the hepatic acinus?

A

the functional microvascular unit of the liver

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12
Q

what does the hepatic acinus consist of? (4)

A
  • terminal portal venule
  • hepatic arteriole
  • bile duct
  • lymph vessels and nerves
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13
Q

describe hepatic blood flow

A

high flow, low resistance

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14
Q

how large of a blood reservoir is the liver?

A 
normal 450ml (10% TBV)
expandable to 0.5-1 L in cases of CHF
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15
Q

the liver contains ____ of all lymph in the body

A

half

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16
Q

the hepatic artery is dependent on _______ to perfuse the liver

A

systemic arterial pressure

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17
Q

a highly compliant liver has ____ ml/mmHg for each 100g of liver weight

A

2-3 ml/mmHg

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18
Q

raising hepatic venous pressure by 1mm/hg results in an increase of ____ ml in a highly compliant liver

A

40-50 ml

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19
Q

regulation of hepatic blood flow is done intrinsicly by

A
  • autoregulation

- metabolic control

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20
Q

regulation of hepatic blood flow is done extrinsically by

A
  • neural control

- humoral control

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21
Q

how will anesthetics affect hepatic blood flow?

A

decrease

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22
Q

how does controlled ventilation affect portal venous blood flow?

A

decrease

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23
Q

regional anesthesia will have what affect on hepatic blood flow?

A

decrease, along with decreasing systemic blood pressure

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24
Q

how will controlled hypotension by sodium nitropresside alter hepatic blood flow?

A

no change, due to an increased portion of blood flow to the portal vascular bed

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25
Q

can the site of surgery affect hepatic blood flow?

A

yes, upper abdominal surgery decreasing flow up to 60%

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26
Q

the liver synthesizes all proteins with the exception of what?

A

gamma globulin

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27
Q

where is albumin produced?

A

the liver

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28
Q

what does albumin do?

A

maintains intravascular oncotic pressure

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29
Q

what is used as a indicator of chronic liver disease?

A

serum albumin

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30
Q

what is a normal serum albumin?

A

3.5-6 g/dl

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31
Q

the liver produces what coagulation factors? (9)

A

vitamin K dependent factors
- II, VII, IX, and X
non-dependent factors
- V, XI, XII, XIII, fibrinogen

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32
Q

what factors are NOT produced byt the liver?

A
  • III (tissue thromboplastin)
  • IV (calcium)
  • VIII (von willebrands)
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33
Q

what is a good indicator of acute hepatic dysfunction?

A
  • PT (prothrombin time)
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34
Q

what % liver function is needed to maintain adequate coagulation?

A

20-30%

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35
Q

what is a byproduct of deaminating amino acids by the liver?

A

ammonia

* can also be produced by GI bacteria

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36
Q

how does the liver remove ammonia?

A

by forming urea

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37
Q

the liver stores large amounts of carbohydrates in the form of what?

A

glycogen

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38
Q

how long until liver glycogen is depleted while NPO

A

24 hours

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39
Q

how does the liver help regulate blood glucose?

A
  • stores glucose as glycogen

- converts carbohydrates, amino acids and TAGs

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40
Q

in PTs with impaired liver function, will glucose go up or down?

A

up, higher than post-meal levels found in normal hepatic function

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41
Q

the majority of cholesterol synthesized in the liver is converted to…

A

bile salts, then secreted in the bile

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42
Q

what phagocytize bacteria entering the liver from the intestines?

A

kupffer cell (macrophages)

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43
Q

how much bacteria does the liver trap using Kupffer cell macrophages before the bacteria can enter systemic circulation?

A

over 99%

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44
Q

red blood cell life span is how long?

A

120 days

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45
Q

heme that is released from the breakdown of hemoglobin is converted into

A

free bilirubin

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46
Q

free, or unconjugated bilirubin, is conjugated in the liver and secreted where?

A

into the bile to be transported to the small intestines

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47
Q

what is jaundice?

A

the yellow-green tint of the body tissue that results from bilirubin accumulation in extracellular fluids

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48
Q

when is skin discoloration of jaundice visibile?

A

when plasma bilirubin reaches 3x normal value

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49
Q

how can bilirubin accumulation occur? (2)

A
  • increased breakdown of hemoglobin (hemolysis)

- obstruction of bile duct

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50
Q

hemolytic jaundice is associated with what?

A

an increase in unconjugated (indirect) bilirubin

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51
Q

obstructive jaundice is associated with what?

A

an increase in conjugated (direct) bilirubin

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52
Q

unconjugated bilirubin (lipid soluble) travels to the liver bound to what?

A

albumin

53
Q

what does the liver do to bilirubin to make it exreteable?

A

conjugates bilirubin to a water-soluble form

54
Q

how much bilirubin is produced daily?

A

300 mg

55
Q

narcotics effect on common bile duct pressure

A

increases

56
Q

what narcotic has the greatest effect on common bile duct pressure

A

fentanyl (increases)

57
Q

how is an increase in bile duct pressure via narcotics attenuated? (4)

A
  • NTG
  • nalonone
  • atropine
  • glucagone
58
Q

what is drug biotransformation?

A

converstion of lipophilic substances to excretable metabolites

59
Q

phase I enzymatic reactions consists of…

A

oxidation by cytochrom P-450 (>90%)

60
Q

phase II enzymatic reactions consist of…

A

conjugation with glucoronic acid to increase water solubility for biliary excretion

61
Q

what factors affect drug metabolism? (5)

A
  • HBF
  • protein binding
  • intrinsic hepatic clearance
  • enzyme inducing compounds
  • self-induced drugs
62
Q

what liver enzyme tests are used to evaluate impaired liver function? (4)

A
  • alkaline phosphatase (ALP)
  • alanine transaminase (ALT)
  • aspartate transaminase (AST)
  • gamma-glutamyl transpeptidase (GGTP)
63
Q

what is the alkaline phosphatase (ALP) test for?

A
  • evaluates liver function

- enzyme levels increased when bile ducts are blocked

64
Q

what is the alanine transaminase (ALT) test for?

A
  • a liver function test

- best for detecting hepatitis

65
Q

what is the aspartate transaminase (AST) test for?

A

evalutates liver function,

not as specific as ALT or ALP

66
Q

what is the gamma-glutamyl transpeptidase (GGTP) test?

A

sensitive marker for cholestatic damage

67
Q

normal alanine aminotransferase (ALT) levels

A

5-40 IU/L

68
Q

normal alkaline phosphatase (ALP) levels

A

13-39 IU/L

69
Q

what (all) tests can be used to evaluate liver function? (7)

A
  • liver enzymes (ALT, ALP, AST, GGT)
  • PT
  • total proteins
  • albumin
  • bilirubin
  • platelets
  • ammonia
70
Q

how is serum albumin effected by liver disease (like cirrhosis)?

A

decreased

71
Q

what clotting factor is associated with acute liver disease?

A

factor VII

72
Q

prothrombin is which factor?

A

factor II

73
Q

whats a normal PT?

A

10-12 seconds

74
Q

PT can be affected by (5)

A
  • liver disease
  • coumarin therapy
  • heparin therapy
  • vit. K def
  • factor VII
75
Q

what is the normal albumin range?

A

3.9-5.0 g/dl

76
Q

conjugated bilirubin is…

A

water soluble for excretion

77
Q

unconjugated bilirubin is…

A

pre-hepatic, not yet processed by liver

78
Q

increased total bilirubin causes…

A

jaundice, leading to

  • hemolytic anemia
  • def. bilirubin metabolism
  • bile duct obstruction
79
Q

if direct bilirubin is elevated, what is going on?

A
  • liver is conjugating bilirubin normally
  • liver cannot secrete bilirubin
  • bile duct obstruction by cancer or gallstones
80
Q

if direct bilirubin is normal in a PT with jaundice, what is going on?

A
  • excess of unconjugated bilirubin

- hemolysis, hepatitis, or cirrhosis should be expected

81
Q

normal total bilirubin range

A

0.2-1.5 mg/dl

82
Q

normal direct (conjugated) bilirubin range

A

0.0-0.03 mg/dl

83
Q

normal indirect (unconjugated) bilirubin range

A

0.2-0.8 mg/dl

84
Q

What are some possible liver diseases?

A
  • hep A, B, C, D, E
  • cirrhosis
  • cholelitiasis, cholecystitis
  • hepatic tumors
85
Q

Hep A manifests as…

A

acute viral hepatitis;

  • fever, jaundice, painfully enlarged liver
  • not common in developed contries
86
Q

Hep B and C are transmitted by…

A
  • blood transfusion
  • needle sticks
  • sexual contact
  • across placenta
87
Q

Hep B manifests as…

A

acute w/ development to fulminant hepatitis and rapid liver destruction

88
Q

is there an available Hep B vaccine?

A

yes

89
Q

what % of hep B will develop chronic hepatitis?

A

10%

90
Q

what % of hep C will develop chronic hepatitis?

A

50%

91
Q

hep C increases risk of developing what?

A
  • cirrhosis (20%)

- hepatocellular carcinoma

92
Q

hep D is a co-infection acquired with…

A

Hep-B

93
Q

what is hep D?

A

an acute infection that can develop into fulminant hepatitis or cirrhosis

94
Q

what is hep E?

A

hepatitis related to poor hygiene or contaminated water

95
Q

which Hepatitis is the greatest risk for anesthesia?

A

Hep B

96
Q

how do you asses Hep B?

A

coagulation pre-op

97
Q

how do you treat hep B?

A
  • FFP
  • monitor glucose
  • maintain normal hepatic flow
  • avoid hypercarbia
98
Q

how can drug metabolism be affected by severe hepatitis?

A

prolonged effect

99
Q

how are benzos affected by hepatic disease?

A

prolonged and more intense effect.

- avoid benzos

100
Q

how are opioids affected by hepatic disease?

A

prolonged effect of morphine and alfentanil

- fentanyl and sufentanil not affected

101
Q

how are non-depolarizing muscle relaxants affected by hepatic disease?

A

prolonged effect

102
Q

what are good choices for muscle relaxant in PTs with hepatic dysfunction? Why?

A

cisatricurium or atracurium

- broken down by plasma esterases

103
Q

what is cirrhosis?

A

liver disease with distortion of normal hepatic structure caused by cell destruction
- leads to liver failure

104
Q

who gets cirrhosis?

A
  • chronic hepatitis

- alcoholics

105
Q

what is cholelitiasis?

A

the formation of calculus (stones) in the gallbladder via cholesteral crystal precipitation

106
Q

what is cholecystitis?

A

inflammation of the gallbladder

107
Q

what should you consider with PTs coming in for a cholecystectomy?

A

RSI, may present with recent N/V

108
Q

why no opioids if the surgeon will be performing a cholangiogram?

A

may cause sphincter of oddi constriction, preventing contrast dye from flowing out of common bile duct

109
Q

what will a PT with jaundice look like?

A

yellowing of the skin and eyes from bilirubin accumulation

110
Q

how much bilirubin in PRBC?

A

250 mg

111
Q

elevation in unconjugated bilirubin can lead to a condition resulting in seizures and brain damage, called what?

A

kernicterus

112
Q

what % of hepatic tumors are hepatocellular?

A

80-90%

113
Q

what % of hepatic tumors have underlying cirrhosis of usually alcoholic origin?

A

75%

114
Q

what are six considerations for hepatic resection?

A 
1 - large bore IV
2 - a-line
3 - central line for CVP
4 - epidural catheter for post-op pain
5 - keep PT hypovolemic during resection
6 - T&C 6 units of blood
115
Q

what is normal portal vein pressure?

A

6-12 cmH2O

8-16 mmHg

116
Q

what is the major clinical manifestation of portal hypertension?

A

GI bleeding

*bleeding in esophagus means severe

117
Q

how do you treat portal hypertension?

A
  • stopping the hemorrhage
  • decompressing portal venous circulation
  • large volume blood transfusion
118
Q

What is a Transjugular Intrahepatic Portosystemic Shunt (TIPS) used for?

A

to decrompress portal circulation in the case of portal hypertension
- buys time waiting for liver transplant

119
Q

what are ascites?

A

ascites is the accumulation of serous fluid in the peritoneal cavity. It compresses abdominal viscera

120
Q

What should you watch for following a decompression of fluid caused by ascites?

A
  • hypovolemia

- hypotension

121
Q

PTs with ascites often present with what?

A

arterial hypoxmia

- PaO2 (60-70 mmHg)

122
Q

how do you treat ascites?

A

induce diuresis with aldactone antagonist (spironolactone)

*1 liter per day max diuresis

123
Q

how can you minimize hypotension caused by managing ascites?

A

IV colloids

124
Q

whats the best treatment of coagulopathy?

A

FFP

125
Q

other than FFP, what can one used to normalized a patients PT?

A

platelets and cryo

126
Q

what is hepatic encephalopathy?

A

hepatic coma

confusion, flapping hands, fruity breath, 88% risk mortality

127
Q

what causes encephalopathy? (3)

A
  • cerebral intoxication (liver not metabolizing GI contents)
  • protein byproducts from bacteria
  • ammonia (NH3) not converted to Urea by liver
128
Q

how do you treat encephalopathy?

A
  • protein restriction
  • antibiotics (neomycin)
  • reduce diuretic therapy
  • treat hypokalemia
  • restrict sedatives

Anesthesia Practice T3 (6 decks)

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