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Bioscience > Hepatic PPT > Flashcards

Hepatic PPT Flashcards

1
Q

GETA for ERCP should include

A

RSI for possible aspiration risk

Standard emergence

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2
Q

ERCP, endoscopic sphincterotomy, and biliary stenting are indicated for?

A

Removal of common duct stones aka choledocholithiasis

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3
Q

Hepatitis B mode of transmission

A

Blood, Body fluids (semen, saliva)

Hepatitis D similar mode of transmission; coinfection with B

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4
Q

How does acute intoxication affect MAC?

A

reduces MAC

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5
Q

Increased risk of bleeding or clotting?

Increased: Factor VIII, vWF, fibrinogen

Decreased: Protein C, protein s, antithrombin III

A

Increased risk of clotting

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6
Q

Mode of transmission for hepatits A?

A

Hepatitis with a vowel come from the bowel

A, E

Fecal-oral, sewage, contaminated shellfish

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7
Q

Altered mental status and asterixis are features in?

A

Hepatic encephalopathy

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8
Q

What drug class can induce sphincter of Oddi tone/spasm

A

Narcotics

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9
Q

*Table Hypoxemia refractory to O2 therapy & PEEP can be due to what effect of cirrhosis?

A

Hepatopulomary syndrome

decreased FRC

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10
Q

Anesthetic management of acute hepatitis

A
  1. Use iso, sevo, or des, avoid halothane
  2. Maintain normocapnia
  3. Avoid PEEP ( if needed no more than 5)
  4. Provide adequate/liberal IV hydration
  5. Consider regional if coagulation is acceptable and procedure allows
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11
Q

If indicated, attempt to correct prothrombin time to within ___seconds of normal.

What is normal PT?

A

2 seconds

Normal PT 10.9-12.5 seconds

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12
Q

What alternative to glucagon can you give for sphincter of oddi spasm

A

Narcan, nalbuphine

nitro, atropine, glycopyrolate

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13
Q

What medications should be avoided in liver disease

A

Hepatotoxic drugs or CYP450 inhibitors

  1. Acetaminophen
  2. Halothane
  3. Amiodarone
  4. ABT: PCN, tetracycline, sulfonamides
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14
Q

What factors should lead to consideration of GETA vs deep sedation for ERCP

A

High aspiration risk

Uncooperative

Complex ercp

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15
Q
A
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16
Q

How to decrease risk of PONV?

A

Treat preemptively

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17
Q

*What are s/s of acute pancreatitis?

A

Sudden onset abd pain gradually becoming more severe

N/V/D

Anorexia

Elevation of pancreatic enzymes

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18
Q

When should you consider using cryo?

A

If FFP ineffective in correcting PT

If a fibrinogen abnormality is present

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19
Q

What is normal intra-abd CO2 insufflation pressure?

A

10-12mm Hg

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20
Q

Lab findings for choledocholithiasis?

A

Increased bilirubin & alkaline phosphatase levels

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21
Q

Cephalad displacement of the diaphragm during trend and subsequent intra abd co2 insufflation can lead to

A

Decreased: lung volumes, lung compliance, FRC, PaO2

Increased:PIP, PaCO2

Atelectasis

Possible change of position of ETT –>endobronchial intubation

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22
Q

Hypercapnia and acidosis have vasoconstrictive or vasodilatory effects on hepatic blood flow? Does it cause an increase or decrease in BF?

A

Vasodilatory effect

Increases HBF

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23
Q

Effects of intra-abd pressure > 15mm Hg

A

Decreased: venous return, CO

Increased: SVR

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24
Q

Apex* What are manifestations of alcohol withdrawal syndrome? Tx?

A

Early: tremors hallucinations, nightmares

Late: Increased SNS activity (tachy, htn, dysrhythmias) N/V, insomnia, confusion, agitation

Tx: Alcohol, BB, Alpha2 agonists

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25
Q

Decreased synthesis/decreased synthetic capacity of the liver is suggested in which lab values

A

Decreased albumin <3.5 g/dL

Prolonged PT time >12.5 Seconds

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26
Q

Describe minor vs major injury d/t halothane

A

Minor injury: increased ALT postop day 1-10

Major injury: Halothane hepatitis

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27
Q

What intraoperative factors contribute to decreased HBF?

A

Hypotension

Hemorrhage

Vasoactive drugs

Pneumoperitoneum (laparoscopy)

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28
Q

*Table What are some cardiovascular effects of liver cirrhosis

A

Fluid retention

Peripheral edema

Ascites

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29
Q

Slow, steadily rising CO2 despite measures to decrease may indicate

A

Subcutaneous emphysema

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30
Q

Most NMB agents are prolonged in patients with liver disease due to what three factors?

A
  1. Reduced pseudocholinesterase activity (sux)
  2. Decreased biliary excretion (roc)
  3. Larger volume of distribution ( as Vd increases drug elimination half life also increases)
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31
Q

*S/S of endobronchial intubation

A

Absent lung sounds in unventilated lobe

Increased PIP unrelated to insufflation pressure

Desaturation

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32
Q

Considerations with cholangiograms

A

Have lead available

Be aware of patients allergies

Prepare to tx hypersensitivity preemptively or acutely prn

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33
Q

* Table Considerations for hepatorenal syndrome include

A

Maintenance of renal perfusion

Caution with drugs eliminated by kidney

Avoidance of nephrotoxic drugs

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34
Q

This complication of laparoscopic sx happens during trocar placement

A

Hemorrhage from inadvertent injury to blood vessels

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35
Q

Table* Hysteroscopies, any previous abd sx, needle/trocar in vessel are all risk factors for?

A

CO2 embolism

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36
Q

*WTH is biliary colic?

A

Pain that occurs when a gallstone is being passed and blocking a bile duct, typically intermittent

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37
Q

In the chronic alcohol abuser who is not acutely intoxicated- is MAC increased or decreased?

A

MAC is increased

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38
Q

Hepatitis is likely to cause elevations in which lab tests ?

A

ALT (10-55units/L)

AST (10-40units/L)

ALT more specific for hepatic injuries

AST nonspecific, can originate from skeletal muscle, rbc, kidney, pancreas, brain and heart

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39
Q

What are some risk factors for liver disease?

A

Excessive alcohol intake IV drug use Use of hepatotoxic medications

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40
Q

* Table Chronic viral hepatitis lab findings

AST/ALT

ALK

Bilirubin

INR

Albumin

A

AST and ALT levels: normal to 10x upper limit of normal

ALK: Normal to slightly elevated

Bilirubin: Normal to elevated

INR: Normal to elevated

Albumin: Normal to decreased

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41
Q

25% of blood flow to the liver comes from where?

A

Hepatic artery

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42
Q

Manifestations of alcohol withdrawal syndrome appear _____ hours

A

24-96

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43
Q

Endocrine features of liver cirrhosis

A
  1. Less glucose production-watch for hypoglycemia
  2. Decreased metabolism of insulin
  3. Hypogonadism
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44
Q

Which VA causes the greatest reduction in hepatic flow?

Intraop or postop?

A

Halothane

Hepatotoxic postop

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45
Q

What measures can be taken to preserve hepatic blood flow in cirrhotic patients?

A
  1. Avoid halothane
  2. Consider regional if procedure and coagulation allow
  3. Maintain normocapnia
  4. Avoid PEEP if possible
  5. Provide generous volume maintenance
  6. Avoid hepatotoxic medications [acetominophen, sulonamides, tetracycline, penicillin, amiodarone]
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46
Q

* Table What are some integument changes in liver cirrhosis

A

Jaundice

Spider angioma

Palmar erythema

Purpura

Petechiae

Caput medusae

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47
Q

Anesthetic plan for lap chole

A

Standard induction and maintenance: GETA with paralysis

48
Q

*Table Name neuro changes r/t liver cirrhosis

A
  1. Hepatic encephalopathy
  2. Peripheral neuropathy
  3. Asterixis
49
Q

Positive pressure ventilation, increased airway pressures and PEEP have what effect on hepatic blood flow?

A

Reduction

50
Q

*How to treat sphincter of Oddi spasm?

A

NNAGG: nitroglycerin, naloxone, atropine, glucagon, glycopyrolate

51
Q

Controlled ventilation during lap chole minimizes the effects of?

A

Pneumoperitoneum and hypercarbia

52
Q

*What is the NMB agent(s) of choice for hepatic or renal dysfunction?

A

Benzylisoquinilines: Cisatracurium or Atracurium

because it uses hydrolysis and hoffman elimination

53
Q

How to decrease the possibility of hypercarbia from absorbed CO2?

A

Ensure adequate ventilation (controlled ventilation) “Never spontaneously breathing no LMA’s”

54
Q

*Table What are some reproductive changes r/t liver cirrhosis?

A

Amenorrhea

Testicular atrophy

Gynecomastia

Impotence

55
Q

*Table Metabolic manifestations of liver cirrhosis include

A
  1. Hypokalemia
  2. Hyponatremia
  3. Hypoalbuminemia
56
Q

* Table Chronic alcoholic liver disease lab findings

AST/ALT

ALK

Bilirubin

INR

Albumin

A

AST:ALT ratio 2:1,

AST/ALT normal to <8x upper limit of normal

ALK: Normal to elevated

Bilirubin: Normal to elevated

INR: Normal to elevated

Albumin: Normal to decreased

57
Q

Reflex dilation of splanchnic capacitance vessels can happen when? What effect does is have on HBF?

A

Traction on abd viscera during intra-abd surgery

Decreases HBF

58
Q

Barash video Laparoscopy highlights

A

Aspirate/decompress the stomach before trocar placement to decrease r/o gastric perforation

Ensure effective co2 elimination via titration MV

Decreased CO, reflex bradyarrhythmia due to vagal stimulation

59
Q

Laparoscopic cholecystectomies have what % of converting to open procedures?

A

5%

60
Q

Pneumothorax can be attributed to what intraoperative process during lap chole?

A

Retroperitoneal dissection of insufflated CO2

61
Q

*Table Liver cirrhosis has this effect on sodium balance

A

Hyponatremia

62
Q

*Table Effects of advanced cirrhosis and portal htn?

A
  1. Normal or low CO
  2. Ascites
  3. Decreased GFR, AKI
63
Q

Keep CO2 insufflation pressure

A

<12 mmHg

64
Q

Table* Hematologic effects of liver cirrhosis

A
  1. Anemia
  2. Thrombocytopenia
  3. Leukopenia
  4. Coagulopathy
  5. Splenomegaly
65
Q

75% of blood flow to the liver comes from?

A

Portal vein

66
Q

* Table Nonalcoholic fatty liver disease lab findings

AST/ALT

ALK

Bilirubin

INR

Albumin

A

AST:ALT ratio <1

AST/ALT levels normal to <5x upper limit of normal

ALK: Normal to 2-3 x upper limit of normal

Bilirubin: Normal to elevated

INR: Normal to elevated

Albumin: Normal to decreased

67
Q

False-positives during a cholangiogram can be caused by

A

Sphincter of Oddi spasm

68
Q

O2 delivery is what % by hepatic artery? portal vein?

A

50% 50%

69
Q

* Table Acute viral hepatitis lab findings

AST/ALT

ALK

Bilirubin

INR

Albumin

A

AST and ALT >25 x upper limits of normal

ALK: Normal to elevated

Bilirubin: Normal to elevated

INR: Normal to elevated

Albumin: Normal to decreased

70
Q

*Table Very careful sterile technique is employed for these patients due to compromised immune system

A

Liver Cirrhosis

71
Q

Upper limit of intra-abd CO2 insufflation pressure?

A

18mm Hg may be tolerated in obese patients

72
Q

S/S of acute cholecystitis include?

A

Abd pain, RUQ tenderness, N/V, fever

73
Q

What are the benefits of carbon dioxide during laparoscopic surgery?

A
  1. Nonflammable
  2. Absorbable
  3. Diffusible
  4. Inexpensive
  5. Transparent
74
Q

*Table Increased risk of GI bleeding stems from what effects of liver cirrhosis?

A

Portal HTN and varices

75
Q

What % of CO does the liver receive?

A

20%- 25% (=1500mL/min)

76
Q

What are the complications of ERCP?

A

Acute pancreatitis, hemorrhage and perforation

77
Q

Which grades of SubQ emphysema will most likely remain intubated?

A

Grades IV and V

78
Q

Hypocapnia and alkalosis exert what effect on hepatic blood flow?

A

Vasoconstricting effects that result in decreased flow

79
Q

*Table What are the effects of cirrhosis and portal htn?

A
  1. High CO
  2. Ascites
  3. Kidneys susceptible to ischemia but normal GFR
80
Q

Table* Tachy, hypotension, increased cvp, hypoxia, cyanosis, ETCO2 biphasic change, Rt heart strain on ecg, increased pulmonary artery pressures on tee are all features of

A

CO2 embolism

81
Q

Other than pneumoperitoneum, what can cause increased airway pressures?

A

Insufficient paralysis

Bronchspasm

Kinked ETT

82
Q

Mode of transmission hepatitis C

A

Percutaneously

Blood and body fluids (semen, saliva)

83
Q

What action can be taken in case of cardiopulmonary compromise during laparoscopic sx

A

Deflate pneumoperitoneum

84
Q

Alcohol _______ GABA receptor activity

A

Increases/potentiates

Enhanced effects of benzos, barbs, propofol, other CNS depressants

85
Q

Hypothermia can be caused by

A

dry gas insufflation

86
Q

Decreased venous return and increased lung volumes are seen in this position

A

Reverse trend

87
Q

During lap chole when is the patient in trend position?

A

Trocar placement

88
Q

*Table Name GI manifestations r/t liver cirrhosis

A

Anorexia

Dyspepsia

N/V

Change in bowel habits

Dull abd pain

Fetor hepaticus (sweet, pungent smell of breath)

Esophageal/gastric/hemorrhoidal varices

Hematemesis

Congestive gastritis

89
Q

* Table Shock liver lab findings

AST/ALT

ALK

Bilirubin

INR

Albumin

A

AST: ALT ratio 1:1

AST and ALT >50x upper limit of normal

ALK: Normal to elevated

Bilirubin: Normal to elevated

INR: Normal to elevated

Albumin: Normal to decreased

90
Q

What are some physical findings of impaired liver function?

A

Hepatomegaly, splenomegaly, spider nevi, gynecomastia, jaundice, ascites, caput medusa

91
Q

Table* Hepatic encephalopathy increases or decreases anesthetic requirements? analgesic requirements?

A

Decreased anesthetic and analgesic requirements

*intubation to protect airway

92
Q

Why is the patient tilted to the left during trend positon?

A

To move away the stomach, duodenum and transverse colon away from the field

93
Q

Bradyarrythmia due to insufflation is usually transient but if sustained and hypotensive tx with?

A

Anticholinergic -Atropine

94
Q

Alcohol inhibits what receptors?

A

NMDA receptor

Acts like NMDA receptor antagonist

95
Q

Which VA causes moderate dose-dependent decrease in hepatic blood flow?

A

Desflurane

96
Q

* Tx of CO2 embolism

A

Stop peritoneal insufflation and desufflate immediately, position patient head down and in left lateral decubitus, hyperventilate with 100% Fio2. If not effective, consider aspiration of embolus from a central line. For massive embolism, CPR/ACLS and ultimately CABG may be needed. In cases of possible cerebral embolism, hyperbaric o2 may be used.

97
Q

Minimal dose-dependent decreases in hepatic blood flow with which VA’s?

A

Iso & Sevo

98
Q

Trend position effect on venous return

A

Increased venous return

99
Q

* Cardiovascular complications of abdominal laparoscopy

A

Decreased venous return

Decreased CO Increased SVR

Decreased blood flow to splanchnic and renal circulation

100
Q

* Table Portopulmonary htn and hyperdynamic circulation present in liver cirrhosis can lead to what complications?

A

Right ventricular failure

cardiogenic shock/ vasodilatory shock

101
Q
A
102
Q

Where does the liver derive its blood supply from?

A

Hepatic artery & portal vein

103
Q

True/false prior abd sx does not increase risk of open procedure

A

False- prior abdominal sx does increase risk of open procedure (scarring, issues with visualization)

104
Q

*In the setting of abd insufflation which MV setting is best?

A

Pressure control mode prevents alveolar derecruitment, provides physiologic minute ventilation while minimizing the risk of barotrauma

105
Q

Decreased PO2, increased PIP, hemodynamic instability and possibly subcuatneous emphysema are manifestations of

A

Pneumothorax

106
Q

To increase duodenal motility during ERCP which drugs may you be asked to give?

A

Glucagon or Secretin

(check BG if glucagon given)

107
Q

Inherent risks of deep sedation

A

Loss of protective airway reflexes

Respiratory depression

108
Q

Portal vein collects blood from where?

A

Blood that leaves the spleen, stomach, small and large intestine, gallbladder and pancreas.

109
Q

Anesthetic plan for acutely intoxicated

A

Aspiration precautions/full stomach

(impaired pharyngeal reflexes d/t alcohol)

RSI

Decreased MAC

110
Q

True/False OGT’s are necessary for lap chole’s

A

True- used to decompress the stomach

111
Q

Lap Chole’s may be contraindicated in what disease states?

A

Uncorrectable coagulopathy

Severe COPD

Severe cardiac disease (unable to tolerate increased intraabd pressure)

112
Q

Hypercapnia & acidosis have what effect on liver blood flow?

A

Vasodilatory effects = increased blood flow

113
Q

Hypocapnia and alkalosis have what effect on liver blood flow?

A

Vasoconstricting effects= decreased blood flow

114
Q

Most common reason for low albumin?

A

chronic liver failure caused by cirrhosis

115
Q

Hepatopulmonary syndrome is defined as the triad of?

A
  1. Liver diease
  2. Arteriolar deoxygenation
  3. Widespread pulmonary vasodilation
116
Q
A

Bioscience (2 decks)

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