ITE GI/Hepatic Flashcards
Mechanism of ischemia-reperfusion injury is thought to be d/t ______
disruption of sodium potassium pumps secondary to lack of ATP
3 phases of liver transplantation
- preanhepatic
- anhepatic
- neohepatic
Preanhepatic stage of liver transplant begins with incision and ends with______
cross-clamping of major vessels of liver (portal vein, hepatic a, IVC or hepatic v)
Serum ____ levels are the strongest predictor of perioperative outcomes in pts receiving TPN
albumin
Acute _____ during abdominal insufflation may result in a huge vagal response (bradycardia, brady arrhythmias, asystole)
stretching of the peritoneum
INR following donor hepatectomy peaks on postop day ___ and returns to normal by day ___. This indicates they at an anticoagulated state compared to others post op.
1-3, 5
- risk of epidural hematoma periop
Lipid emulsions are an important component of TPN bc _______ is the predominant energy producing pathway states of stress (sepsis, burns, surgery)
lipid oxidation
Nutritional support via enteral or parenteral routes should be given to all pts who are not expected to resume PO intake w/in ____ days post op
7 days
Absolute indications for TPN
- short bowel syndrome
- SBO
- Active GI bleed
- Pseudo obstruction w/ complete intolerance to food
- High output enteric cutaneous fistulas
Hepatorenal syndrome in a cirrotic pt w/ ascites has a risk of 40% at 5 years. It is caused by _____
portal HTN and resultant reduction in renal perfusion
Type 1 vs Type 2 Hepatorenal syndrome
Type 1: acute rapid renal failure w/ precipitating cause (SBP, sepsis, surgery)
Type 2: insidious onset of RF as a result of portal HTN
Portopulmonary HTN definition
pulmonary HTN (25 mmHg at rest, 30 mmHg during exercise) in a pt w/ portal HTN w/ no other known cause
Hepatopulmonary syndrome triad
- Liver dysfunction
- unexplained hypoxia
- Intrapulmonary vascular dilations (IPVDs)
Plasma albumin has a half life of ___
3 weeks
- acute decreases in liver fxn may not cause decrease in serum albumin [ ]
*PTT is a better marker of liver fxn
AST:ALT of ___ is common in alcoholic liver disease and ____ in nonalcoholic steatohepatitis
2-4
<1
(AST/ALT) is specific to hepatic origin
ALT
- think L for liver
Morbidly obese pts have an increase in _____ and ____, which can decrease the duration of action of succinylcholine and require larger doses
butyrylcholinesterase (pseudocholinesterase)
Extracellular fluid volume
Medications that should be calculated based on TBW
maintenance gtt of propofol
Succinylcholine
Neostigmine
Sugammadex
Medications that should be calculated based on lean body weight
thiopental
induction dose propofol
fentanyl, alfentanil, remifentanyl
Etomidate
Medications that should be calculated based on IBW
rocuronium
vecuronium
pancuronium
Advance liver disease, what happens to:
- platelets
- VWF
- coagulation factors
- PT/INR
- platelets: decrease
- VWF: increase
- coagulation factors: decrease (most are synth in liver)
- INR: increase
*thrombocytopenia is a well known feature of cirrhosis
2,3- DPG levels (increase/decrease) in cirrhotic pts, shifting the hgb dissociation curve to the (right/left)
increase
right
Alvimopan is a ____ receptor antagonist that (does/does not) cross the BBB
mu-receptor antagonist
- combats opioid activity in gut
- allows opioid activity in the CNS
Loperamide is a ____ used to slow gut motility and manage diarrhea
mu receptor agonist
- does not penetrate BBB
Why is using lean body weight for med dosing sometimes ideal?
It is most correlated to cardiac output
Medications that use total body weigh
fentanyl
sufentanil
propofol maintenance
thiopental
Morbidly obese pts have an (increase/decrease) cardiac output
increase
- alters elimination and delivery to kidney and liver
Morbidly obese pts have an (increase/decrease) hepatic clearance
no change
in the brain, ____ are the primary cell that metabolizes ammonia. These cells convert ammonia to _____, which acts as an osmotic agent, pulling water into the _____, and resulting in cerebral edema
astrocytes
glutamine
astrocytes
Acute hepatic encephalopathy is physiologically d/t ______ and ______
increase ammonia –> fluid shift -> swelling of the astrocytes –> cerebral edema
profound cerebral vasodilation from loss of autoregulation
Acute liver failure mortality is worse in (hyperacute/acute/subacute) liver failure
acute (8-28days) following liver injury
(acidemia/alkalemia) increases the diffusion of ammonia across the BBB and can worsen or precipitate hepatic encephalopathy in pts with chromic liver disease
alkalemia
____ is the most common medication used for both prophylaxis and tx of hepatic encephalopathy
lactulose
Effects of enteric feeds:
- Gluconeogenesis
- lipolysis
- insulin secretion
- Gluconeogenesis: decrease
- lipolysis: decreases
- insulin secretion: increase
*enteric feeds do not enter gluconeogenesis pathway,
whereas non-enteric feeds do enter gluconeogenesis pathway
______ is used by rapidly dividing cells and is a precursor of nucleotides. It is often decreased in states of stress.
Glutamine