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Pathophys II > Hepatic pearls > Flashcards

Hepatic pearls Flashcards

1
Q

acute hepatitis is the result of

A

viral infection, drug reaction, & exposure to hepatotoxin

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2
Q

Hep C produces

A

asymptomatic carriers

no effective vaccine is currently available

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3
Q

Infectious carriers pose a major health threat to OR personnel:

A

avoid direct contact with blood & secretions
immunization is highly effective against hep B infection
No vaccine for hep C is available and prior infection does not confer immunity upon re-exposure
post-exposure prophylaxis with hyperimmune globulin is effective for Hep B not C

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4
Q

Most common cause of drug-induced hepatitis is

A

Alcohol induced

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5
Q

Patients with hepatitis are at risk for further hepatic dysfunction & hepatic failure:

A

encephalopathy
coagulopathy
Hepatorenal syndrome

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6
Q

Acute hepatitis preop labs that should be addressed include:

A

Bilirubin, albumin, prothrombin time

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7
Q

In acute hepatitis, (describe what happens with transaminases)

A

elevated transaminases do not correlate well with the degree of cellular necrosis

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8
Q

Prolongation with INR >1.5 following administration of Vitamin K is indicative of

A

severe liver dysfunction

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9
Q

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

A
  • determination of the cause & degree of hepatic impairment
  • record drug exposures including- alcohol intake, rec drug use, recent transfusions, & prior anesthetics
  • presence of N/V
  • correct dehydration & electrolyte abnormalities
  • mental status changes suggest severe hepatic impairment
  • alcoholics- signs of withdrawal vs. signs of acute toxicity
  • premeds like benzos are generally not given to minimize drug exposure & confounds encephalopathy
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10
Q

Goal of intraoperative management for the acute hepatitis patient is

A

preserve existing hepatic function

avoid factors that may be detrimental to the liver

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11
Q

The volatile agent of choice due to the least effect on hepatic blood flow is

A

isoflurane

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12
Q

“Standard” induction doses of IV agents can generally be used as

A

their action is terminated by redistribution versus metabolism or excretion

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13
Q

If large or repeated doses of IV agents are administered to the patient with hepatitis,

A

prolonged duration of action may occur (particularly w/ opiods)

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14
Q

Avoid the following things that are known to reduce hepatic blood flow:

A

sympathetic stimulation, hypotension, high mean airway pressures

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15
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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16
Q

Patient classification of chronic hepatitis is determined by

A

liver biopsy

syndromes include- chronic persistent hepatitis, chronic lobular hepatitis, & chronic active hepatitis

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17
Q

Chronic persisitent hepatitis

A

eventually resolves
usually does not progress to cirrhosis
characterized by chronic inflammation of the portal tracts with preservation of the NORMAL cellular architecture

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18
Q

Chronic lobular hepatitis is

A

resolves but followed by recurrent exacerbations
characterized by foci of inflammation & cellular necrosis in the lobules
usually does not progress to cirrhosis

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19
Q

Chronic active hepatitis

A

chronic hepatic inflammation with destruction of cellular architecture
evidence of cirrhosis present initially or eventually develops

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20
Q

Describe the anesthetic management for patients with chronic persistent, chronic lobular, and chronic active hepatitis

A

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

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21
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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22
Q

Regardless of the cause of cirrhosis, the result is

A

hepatocyte necrosis followed by fibrosis & nodular regeneration

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23
Q

Vitamin K requires

A

24 hours for a full response

24
Q

These complications eventually develop in most patients with cirrhosis:

A

jaundice & ascites

25
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

26
Q

Preoperative considerations for the patient with cirrhosis include

A

prevent or limit complications

can affect all organ systems: GI, circulatory, pulm, renal, hematological, infectious, metabolic, & neurological

27
Q

The severity of hepatic impairment & surgical risk can be

A

estimated using the Childs-Turcotte- Pugh scoring system

-has 2 clinical features & 3 lab assesssments

28
Q

List what is included in the Childs- Turcotte Pugh score assessment:

A

total bilirubin, serum albumin, INR, ascites, & hepatic encephalopathy

29
Q

Gastrointestinal manifestations of cirrhosis include:

A

extensive venous collateral channels- gastroesophageal

hemorrhoidal, periumbilical, & retroperitoneal

30
Q

A major source of morbidity & mortality for the patient with cirrhosis is:

A

massive bleeding from gastroesophageal varices
medical tx. includes balloon tamponade, replace blood loss, vasopressin, somatostatin, & propranolol to reduce rate of blood loss

31
Q

The hematological manifestations of the cirrhotic patient include

A

anemia, thrombocytopenia/coagulopathy, & leukopenia (usually due to things backing up in the spleen)

32
Q

In regards to preoperative blood transfusions, _____ can precipitate encepalopathy

A

protein breakdown from excessive blood transfusions

33
Q

Circulatory manifestations of cirrhosis include:

A

cardiac output is often increased & generalized peripheral vasodilation is present (similar to sepsis)
- AV shunts can develop in the systemic & pulmonary circulation

34
Q

Cirrhotic cardiomyopathy may be present due

A

increased cardiac output as a result of above normal filling pressures and below normal SVR

35
Q

Mechanisms believed to be responsible for ascites include:

A

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

36
Q

Respiratory manifestations of cirrhosis include

A

hyperventilation is common and results in primary respiratory alkalosis

37
Q

Hypoxemia is frequent due to

A

right to left shunts

  • shunting is due to increase anomalous AV
  • Also have V/Q mismatch
  • up to 40% of CO is involved
38
Q

Ascites fluid (resp. issues)

A

causes an elevation of the diaphragm leading to decreased lung volumes (particularly FRC) resulting in atelectasis

39
Q

Renal manifestations & fluid balance abnormalities are most severe with

A

the onset of hepatorenal syndrome

40
Q

Hepatorenal syndrome is characterized by:

A

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

41
Q

Hepatorenal syndrome usually follows

A

GI bleeding, aggressive diuresis, sepsis, & major surgery

42
Q

Acute intravascular fluid deficits should be corrected with

A

colloid infusion

43
Q

Hepatic encephalopathy is characterized by

A

alterations in mental status, fluctuating neurological signs (asterixis, hyperreflexia), EEG changes, & increased ICP

44
Q

________ has been implicated in the development of hepatic encepalopathy

A

accumulation of toxins originating in the GI tract & normally metabolized in the liver (ammonia, phenols)

45
Q

Response to drugs is unpredictable due to changes in

A

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

46
Q

Volume of distribution of highly ionized NMBAs is increased therefore:

A

requires greater than normal loading dose

47
Q

Hepatic elimination of NMBAs is decreased therefore

A

requires lower than normal maintenance dose

48
Q

The best thing you can do with your drugs is

A

titrate them

49
Q

The cirrhotic liver is very dependent on

A

hepatic ARTERIAL blood flow due to reduced portal blood flow

50
Q

Induction with ____ is recommended

A

propofol

cisatricurium is the NMBA of choice

51
Q

Removal of large amounts of ascites fluid may require

A

IV colloid solutions to prevent profound hypotension

52
Q

Significant transfusions can result in citrate toxicity. IV

A

Ca2+ is often necessary to reverse the negative inotropic effects of decreased ionized Ca

53
Q

The most common cause of cholestasis is

A

extrahepatic obstruction

due to gallstones, stricture, tumor in the common hepatic duct

54
Q

Cholestasis can also be caused by

A

intrahepatic obstruction due to
suppression or stoppage of bile flow in the bile canalciulus
results from viral hepatitis or idiosyncratic drug reaction

55
Q

Treatment of extrahepatic obstruction vs. intrahepatic

A

extrahepatic- surgical

intrahepatic- medical

56
Q

Both intrahepatic & extrahepatic produce a

A

predominantly conjugated hyperbilirubinemia & marked elevation in alk phos

57
Q

Hepatobiliary disease is characterized by

A

cholestasis- suppression or stoppage of bile flow

Pathophys II (43 decks)

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