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Pathophys II > Hepatic Part 3 > Flashcards

Hepatic Part 3 Flashcards

1
Q

Preoperative considerations for the patient with acute hepatitis include

A

postpone elective surgery until resolved as determined by normal liver function test
-increased periop morbidity & mortality during acute phase

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2
Q

Perioperative considerations for patients with acute alcoholic hepatitis includes

A

risk with alcoholic hepatitis may not be as great

but patients could suffer from withdrawal during surgery and this is associated with a high mortality rate

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3
Q

Patients with hepatitis are at risk for further hepatic dysfunction and hepatic failure include

A

encephalopathy, coagulopathy, & hepatorenal syndrome

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4
Q

For patients who are chronic alcoholics, hypomagnesemia may occur

A

which predisposes to dysrhythmias

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5
Q

Lab evaluation of the patient with acute hepatitis includes

A

BUN, creatinine, bilirubin, electrolytes, glucose, transaminases, alkaline phosphatase, albumin, prothrombin time (INR), platelet count
serum HBsAg
blood alcohol level

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6
Q

Elevated transaminases do not

A

correlate well with the degree of cellular necrosis

bilirubin & alkaline phosphatase are usually only moderately elevated except with the cholestatic variant

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7
Q

For patients with acute hepatitis, describe levels of ALT & AST

A

ALT>AST

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8
Q

For patients with alcoholic hepatitis, describe levels of ALT & AST

A

AST> ALT

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9
Q

Hypoalbuminemia is usually not present except in

A

protracted cases with severe malnutrition (or chronic hepatitis)

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10
Q

The best indicator of synthetic function of the liver with hepatitis is

A

PT

prolongation> 3 to 4 seconds following administration of Vitamin K is indicative of severe liver dysfunction

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11
Q

Preoperative evaluation of the emergent patient with acute hepatitis should include:

A

determination of the cause & degree of hepatic impairment
record drug exposures
presence of N/V–> may necessitate cricoid pressure
correction of dehydration & electrolyte abnormalities
mental status changes suggest severe hepatic impairment
premedication generally is not given to minimize drug exposure and confounds encephalopathy in patients with advanced liver disease

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12
Q

Recording of drug exposures for the acute hepatic patient should include

A

alcohol intake, recreational drug use, recent transfusions, & prior anesthetics

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13
Q

For alcoholics with acute hepatitis, the preoperative evaluation includse

A

inappropriate behavior or obtunded patient is a sign of acute toxicity
irritability, tremulousness, HTN, and tachycardia are signs of withdrawal

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14
Q

Vitamin K may be necessary to correct

A

a coagulopathy

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15
Q

The goal of intraoperative management of acute hepatitis is

A

to preserve existing hepatic function

avoid factors that may be detrimental to the liver

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16
Q

Intraoperative management of the patient with acute hepatitis includes

A

drug selection & doses should be individualized

acute viral hepatitis may produce increased CNS sensitivity to anesthetics

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17
Q

Intraoperative management of the alcoholic patient includes:

A

display cross-tolerance to IV and volatile anesthetic agents
requires CV monitoring due to the additive depressant effects of anesthetics & alcohol, possible presence of alcoholic cardiomyopathy

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18
Q

Patient classification of the patient with hepatitis is based on three distinct syndromes and is determined by

A

liver biopsy

chronic persistent hepatitis, chronic lobular hepatitis, & chronic active hepatitis

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19
Q

Chronic hepatitis is defined as

A

persistent hepatic inflammation for longer than 6 months as evidenced by elevated serum aminotransferases

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20
Q

In patients with acute hepatitis, intraoperative considerations include avoiding things known to reduce hepatic blood flow such as

A

hypotension, excessive SNS stimulation, high mean airway pressures during controlled ventilation

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21
Q

Intraoperative considerations for the patient with acute hepatitis include using “standard” induction doses of IV agents since their action is

A

terminated by redistribution versus metabolism or excretion

-prolonged duration of action may occur if large or repeated doses of IV agents are administered (particularly opioids)

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22
Q

The volatile agent of choice for the patient with acute hepatitis is

A

isoflurane as it has the least effect on hepatic blood flow

-inhalation agents are generally preferable to IV agents due to the dependence on liver metabolism and elimination

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23
Q

Additional considerations for the intraoperative management of the acute hepatitis patient includes

A

fewest number of anesthetic agents should be used

regional anesthesia can be used in the absence of coagulopathy

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24
Q

Describe chronic persistent hepatitis.

A

present with acute hepatitis (usually B or C) that has a protracted course but eventually resolves
characterized by chronic inflammation of the portal tracts with preservation of the normal cellular architecture (don’t have a lot of cell death with this)
usually does not progress to cirrhosis

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25
Q

Describe chronic lobular hepatitis.

A

present with acute hepatitis that resolves but followed by recurrent exacerbations
-characterized by FOCI of inflammation and cellular necrosis in the lobules
usually does not progress to cirrhosis

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26
Q

Describe chronic active hepatitis.

A

occurs most commonly as a sequela of hepatitis B or C
characterized by chronic hepatic inflammation with destruction of cellular architecture
evidence of cirrhosis present initially or eventually develops

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27
Q

Patients with hep B or C infection usually have a favorable response to

A

antiviral medications
Hep B: antiviral + immune modulator drugs (interferon)
Hep C: antiviral can cure more than 95% of affected patients

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28
Q

Anesthetic management for the patient with chronic hepatitis includes:

A

patients with chronic persistent or chronic lobular hepatitis should be treated similar to those with acute hepatitis
patients with chronic active hepatitis should be assumed to have cirrhosis and treated as such

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29
Q

For the patient with chronic hepatitis, laboratory test may show

A

only mild elevation of serum aminotransferases and generally these correlate poorly with severity of the disease

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30
Q

Cirrhosis is a progressive disease that eventually results in

A

hepatic failure

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31
Q

Most common causes of cirrhosis include:

A

alcohol abuse, NALFD, chronic active hepatitis (B & C), chronic biliary inflammation or obstruction

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32
Q

Regardless of the cause of cirrhosis, the result is

A

hepatocyte necrosis followed by fibrosis and nodular regeneration (scar tissue)

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33
Q

Destruction of the livers normal cellular and vascular architecture in the patient with cirrhosis produces:

A

obstruction of the portal venous flow leading to portal hypertension
impairment of normal synthetic and metabolic functions leading to multisystem disease

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34
Q

3 major complications associated with cirrhosis include

A

variceal hemorrhage from portal hypertension
intractable fluid retention in the form of ascites
hepatic encephalopathy or coma

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35
Q

Approximately 10% of patients with cirrhosis have at least one episode of

A

bacterial peritonitis and some may eventually develop hepatocellular carcinoma

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36
Q

Manifestations of the patient with cirrhosis include

A

jaundice & ascites

other manifestations include: spider angiomas, palmar erythema, gynecomastia, spleenomegaly

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37
Q

Patients with cirrhosis are at increased risk for further deterioration of liver function due to

A

detrimental effects of anesthesia and surgery on hepatic blood flow
already limited hepatic reserve

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38
Q

Successful anesthetic management depends on recognizing the multisystem dysfunction with cirrhosis

A

GI, circulatory, pulm, renal, hematological, infections, metabolic, & neurological
the goal is to prevent or limit complications

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39
Q

Preoperative considerations for the patient with cirrhosis include

A

surgical risk is correlated with the degree of hepatic impairment
severity of hepatic impairment and surgical risk can be estimated used the Childs-Turcotte-Pugh scoring system

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40
Q

The Childs=Turcotte-Pugh score measures:

A

total bilirubin, serum albumin, INR, ascites, & hepatic encephalopathy
-assigning points based on levels and this helps determine survival

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41
Q

Gastrointestinal manifestations of the cirrhotic patient includes

A

portal hypertension leads to development of extensive venous collateral channels: gastroesophageal, hemorrhoidal, periumbilical, & retroperitoneal

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42
Q

The preoperative sign of portal hypertension is

A

abdominal wall veins

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43
Q

Massive bleeding from gastroesophageal varices is a major cause of morbidity & mortality and medical treatment includes

A

replace blood loss with IV fluids & blood products
vasopressin, somatostatin, & propranolol to reduce the rate of blood loss
balloon tamponade
endoscopic sclerosis or ligation of the varices is about 90% effective
bleeding continues or reoccurs then emergency surgery is indicated

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44
Q

Patients with cirrhosis may present with

A

anemia, thrombocytopenia/coagulopathy, leukopenia

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45
Q

For the patient with cirrhosis who has anemia, it is associated with

A

blood loss, increased RBC destruction, bone marrow suppression, & nutritional deficiencies

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46
Q

Thrombocytopenia/coagulopathy in the patient with cirrhosis is associated with

A

congestive spleenomegaly due to portal hypertension
decreased hepatic synthesis of clotting factors
enhanced fibrinolysis due to reduced elimination of factors that activate the fibrinolytic system

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47
Q

Leukopenia in the patient with cirrhosis is associated with

A

congestive spleenomegaly due to portal hypertension

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48
Q

Cirrhotic cardiomyopathy may be present due to

A

arteriovenous shunts & decreased blood viscosity

contribute to increased CO: above normal filling pressures, below normal SVR

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49
Q

Superimposed alcoholic cardiomyopathy may readily lead to

A

CHF

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50
Q

Circulatory manifestations of cirrhosis include

A

cirrhosis is typically associated with a hyperdynamic circulatory state
CO is often increased and generalized peripheral vasodilation is present
AV shunts can develop in the systemic and pulmonary circulation

51
Q

Preoperative blood transfusion consideration sinclude:

A

protein breakdown from excessive blood transfusion can precipitate encephalopathy
coagulopathy should still be corrected before surgery
clotting factors should be replaced with blood products such as FFP & cryo
platelet transfusion should be considered immediately prior to surgery for platelet count < 100,000

52
Q

Describe the respiratory manifestations for a patient with cirrhosis.

A

hyperventilation is common resulting in resp alkalosis
hypoxemia is frequent due to right to left shunts
decrease lung volumes (particularly FRC) due to ascites fluid elevation of the diaphragm–> results in atelectasis

53
Q

Describe why hypoxemia occurs in patients with cirrhosis.

A

shunting is due to increased anomalous AV communication
also have V/Q mismatch
up to 40% of CO involved

54
Q

Describe preop labs/procedures that should be performed related to the respiratory manifestations of the patient with cirrhosis.

A

chest film & ABG to diagnose hypoxemia & atelectasis as they may not be evident from clinical examination
paracentesis should be considered for massive ascites with pulmonary compromise

55
Q

Alterations in fluid & electrolyte balance are manifested as

A

ascites, edema, electrolyte abnormalities, & hepatorenal syndrome

56
Q

The following methods are believed to be responsible for ascites:

A

portal hypertension
hypoalbuminemia
seepage of protein-rich lymph fluid from the surface of the liver
avid renal sodium (& often water) retention

57
Q

Describe how portal hypertension leads to ascites.

A

increased hydrostatic pressure favors fluid transudation across the intestine into the peritoneum

58
Q

Describe how hypoalbuminemia leads to ascites.

A

decreases plasma osmotic pressure favors fluid transudation

59
Q

Describe how seepage of protein-rich lymph fluid from the surface of the liver leads to ascites.

A

secondary to distortion and obstruction of lymphatic channels

60
Q

Describe how avid renal sodium (and often water) retention lead to ascites.

A

hepatorenal syndrome

61
Q

In relation to renal manifestations & fluid balance, patients with cirrhosis and ascites have

A

decreased renal perfusion
altered intrarenal hemodynamics
enhanced proximal and distal tubule Na+ reabsorption
impairment of free water clearance

62
Q

Describe the electrolyte abnormalities of the patient with cirrhosis and ascites.

A

hyponatremia is common- dilutional

hypokalemia is common- excessive K+ loss secondary to hyperaldosteronism or diuretics

63
Q

The renal manifestations and fluid balance abnormalities in cirrhosis are most severe with the onset of

A

hepatorenal syndrome

64
Q

Hepatorenal syndrome is afunctional deficit in patients with cirrhosis that usually follows:

A

gastrointestinal bleeding
aggressive diuresis
sepsis
major surgery

65
Q

Hepatorenal syndrome is characterized by

A

progressive oliguria, avid Na+ retention, azotemia, intractable ascites, & very high mortality rate

66
Q

Treatment for hepatorenal syndrome is

A

supportive in nature and often unsuccessful unless a liver transplant is performed

67
Q

The anesthetic management of the cirrhotic patient with renal manifestations and fluid balance includes:

A

judicious use of periop fluid management
use colloid infusion for fluid correction
avoid overzealous preop diuresis
importance of preserving renal function periop is critical
diuresis of ascites and edema should be accomplished over several days

68
Q

Loop diuretics should only be used after

A

bed rest, Na restriction, and spironolactone therapy have failed

69
Q

Hepatic encephalopathy is characterized by

A

alterations in mental status
fluctuating neurological signs- asterixis, hyperreflexia
EEG changes
some patients also have increased ICP

70
Q

Metabolic encephalopathy may be related to the amount of

A

hepatocellular damage and degree of shunting of portal blood directly into the systemic circulation

71
Q

Accumulation of toxins originating in the GI tract and normally metabolized in the liver that may cause hepatic encephalopathy include:

A

ammonia
methionine metabolites
short chain fatty acids
phenols

72
Q

Encephalopathy should be treated

A

preoperatively

73
Q

It is recommended to avoid ____ in patients with encephalopathy

A

sedatives

74
Q

Factors known to precipitate hepatic encephalopathy include

A

GI bleeding, increased dietary protein intake, hypokalemic alkalosis from vomiting or diuresis, infections, worsening liver function

75
Q

The drug response to agents is unpredictable due to changes in

A

CNS sensitivity, volume of distribution, protein binding, drug metabolism & drug elimination

76
Q

The most important thing we can do with our drugs for liver patients include

A

titration!

77
Q

Volume of distribution of highly ionized NMBAs is increased & therefore

A

it requires greater than normal loading doses

78
Q

hepatic elimination of NMBAs is decreased and therefore requires

A

lower than normal maintenance doses

79
Q

The cirrhotic liver is very dependent on

A

hepatic arterial blood flow due to reduced portal blood flow

80
Q

Preservation of hepatic arterial blood flow is critical in the cirrhotic patient and we can do this by

A

avoiding anesthetic agents that potentially reduce hepatic arterial blood flow

81
Q

Regional anesthesia can be used in cirrhotic patients without

A

thrombocytopenia or coagulopathy but must take great care to avoid hypotension

82
Q

The most highly recommended anesthesia for the cirrhotic patient is

A

propofol induction with isoflurane maintenance in oxygen or air-oxygen with Cisatricurium as the NMBD

83
Q

Cardiovascularly unstable patients and those with active bleeding should have

A

awake intubation or RSI with cricoid pressure using ketamine or etomidate and succinylcholine

84
Q

RSI with cricoid pressure may be indicated for the liver patient because

A

preoperative nausea, vomiting, GI bleeding, and abdominal distension

85
Q

Opioid supplementation for the cirrhotic patient will

A

reduce the volatile agent requirement but have prolonged half life leading to prolonged respiratory depression

86
Q

Monitoring of the cirrhotic patient includes:

A

monitor 5 lead EKG to detect ischemia (particularly in patients receiving vasopressin as they may have cirrhotic and alcoholic cardiomyopathy)

  • supplement pulse ox with ABGs to evaluate acid base status
  • patients with large R to L shunts may not tolerate N2O & may require PEEP
  • catheter to monitor UO- consider mannitol for persistent low urine output
87
Q

Most patients with cirrhosis should have intrarterial monitoring due to rapid changes in BP as a result of

A

excessive bleeding, rapid intercompartmental fluid shifts & surgical manipulations

88
Q

Intravascular volume is difficult to assess in cirrhotic patients and therefore they may need

A

CVP or PAP monitoring

89
Q

When evacuating ascites fluid, consider that removal of large amounts of ascites fluid may require

A

IV colloid solutions to prevent profound hypotension

90
Q

Fluid shifts can occur in patients who have

A

prolonged surgical procedures & evacuation of ascites fluid

91
Q

Intraabdominal procedures in the patient with cirrhosis are often associated with

A

excessive bleeding due to venous engorgement from portal hypertension, adhesions from previous surgery, coagulopathy

92
Q

For fluid replacement in the cirrhotic patient, most patients are on Na+ restriction preoperatively. Intraoperatively preservation of intravascular fluid volume and urinary output

A

takes precedence

use of predominantly colloid solutions may be preferable to avoid Na+ overload and to increase plasma osmotic pressure

93
Q

Most patients are anemic & have a coagulopathy and therefore require

A

RBC transfusion preoperatively

94
Q

Significant transfusions can result in citrate toxicity because

A

citrate is normally metabolized by the liver
cirrhosis impairs citrate metabolism
citrate binds to serum Ca++ and leads to hypocalcemia
IV Ca++ is often necessary to reverse the negative inotropic effects of decreased ionized Ca

95
Q

Treatment of extrahepatic obstruction is usually

A

surgical

96
Q

Treatment of intrahepatic cholestasis is

A

medical

97
Q

Both extrahepatic & intrahepatic obstruction produce a

A

predominantly conjugated hyperbilirubinemia and marked elevation in alk phos

98
Q

Patients with symptomatic gallstone disease (cholelithiasis) usually present with

A

biliary colic secondary to obstruction of the cystic duct

99
Q

Cholangitis is suggestive due to

A

concomitant chills or high fever suggesting an ascending bacterial infection of the biliary system

100
Q

Gallstones can obstruct the

A

pancreatic duct and cause acute pancreatitis

101
Q

The most common cause of cholestasis is

A

extrahepatic obstruction of the biliary tract (obstructive jaundice)

102
Q

Extrahepatic obstruction can be due to

A

gallstones, stricture, & tumor in the common hepatic duct

103
Q

Cholestasis can also be caused by

A

intrahepatic obstruction

104
Q

Intrahepatic obstruction can be due to

A

suppression or stoppage of bile flow at the level of the hepatocyte or bile canaliculus
most commonly results from viral hepatitis or idiosyncratic drug reaction

105
Q

Hepatobiliary disease is characterized by

A

cholestasis- suppression of stoppage of bile flow

106
Q

Patients with hepatobiliary disease most commonly present to the OR for

A

cholecystectomy

107
Q

Patients with acute cholecystitis should be treated

A

medically before coming to the OR

108
Q

Treatment for acute cholecystitis includes

A

nasogastric suction, IV fluids, antibiotics, and opioid analgesics

109
Q

Patients suffering from serious complications related to hepatobiliary disease may require

A

emergency cholecystectomy as it is resulting in destruction of hepatocytes

110
Q

Patients with extrahepatic biliary obstruction from an cause readily develop

A

vitamin K deficiency

  • should be given vitamin K (requires 24 hours for a full response)
  • failure of the PT to correct prior to surgery may necessitate FFP
111
Q

High bilirubin levels for the patient with hepatobiliary disease may be associated with

A

renal failure

112
Q

Long standing extrahepatic biliary obstruction is associated with secondary

A

biliary cirrhosis & portal hypertension

113
Q

Laparoscopy cholecystectomy will accelerate

A

recovery

114
Q

Describe the use of opioids when an intraoperative cholangiogram is to be performed.

A

can be problematic
opioid induced spasm of the sphincter of Oddi may theoretically result in a false-positive cholangiogram
-some clinicians withhold opioids until after the cholangiogram has been performed
sphincter of Oddi spasm can be treated with naloxone or glucagon

115
Q

In patients with a biliary tract obstruction expect a prolonged

A

duration of action of drugs that are dependent on biliary excretion
agents dependent on renal excretion are preferable

116
Q

Common hepatic surgeries include

A

repair of lacerations, drainage of abscesses, & resection of tumors

117
Q

How much of the liver can be resected?

A

80 to 85%

118
Q

Cirrhosis greatly complicates anesthetic management and increases periop mortality, preparation includes

A

multiple large bore IVs, fluid & blood warmers, rapid infusion devices, direct arterial & CVP monitoring advisable, & avoidance of hypotension

119
Q

Postoperative complications of hepatic surgery include

A

bleeding, sepsis, & hepatic dysfunction

120
Q

Postoperative __________ may be necessary in patient undergoing extensive resection

A

mechanical ventilation

121
Q

______ may occur following large liver resections

A

hypoglycemia

122
Q

Drainage of an abscess may be complicated by

A

peritoneal contamination

123
Q

Administration of ____ may reduce blood loss.

A

antifibrinolytics; aprotinin, aminocaproic acid, tranexamic acid

Pathophys II (43 decks)

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