LIVER

Question 0

WHAT TYPE OF RECEPTORS ARE FOUND IN THE HEPATOCYTE PLASMA MEMBRANE?

Answer 0

ADRENERGIC RECEPTORS WITH ALPHA REC. PREDOMINATING. THIS CAUSES INCREASED CALCIUM ION CONCENTRATION INTRACELLULARLY.

Question 1

WHAT DOES THE HEPATIC VEIN DRAIN INTO?

Answer 1

THE INFERIOR VENA CAVA

Question 2

WHAT ARE THE FUNCTIONS OF THE LIVER?

Answer 2

ABSORB NUTRIENTS COMING IN…( PORTAL VENOUS BLOOD), STORE/RELEASE PROTEIN LIPIDS CARBS, EXCRETE BILE SALTS, METABOLIZE COMPOUNDS, AND FUNCTIONS AS A BLOOD RESEVOIR, PRODUCES LYMPHATIC FLUID.

Question 3

WHY IS DECREASED ALBUMIN WITH LIVER DISEASE A CONSIDERATION FOR ANESTHESIA?

Answer 3

ALBUMIN IS IMPORTANT FOR DRUG BINDING. LESS ALBUMIN MEANS MORE FREE LEVELS OF DRUGS IN BLOOD…AND LONGER DURATION. (WHEN ALBUMIN <2.5)

IT TAKES ABOUT 14 DAYS TO SEE A DECREASE IN ALBUMIN DUE TO LONG 1/2 LIFE. SO YOU MAY NOT SEE THIS IN ACUTE LIVER INJURY.

Question 4

HOW ARE SUBSTANCES METABOLIZED BY THE LIVER? (RXNS)

Answer 4

PHASE 1 RXN: MODIFY CHEMICALS (OXIDATION, REDUCTION, HYDROLYSIS) THIS IS IMPORTANT FOR ANESTHETICS.
PHASE 2 RXN: CONJUGATE WITH OTHER SUBSTANCES TO BE ELIMINATED IN URINE/BILE.

Question 5

HOW IS BLOOD SUPPLIED TO THE LIVER?

Answer 5

VIA PORTAL VEIN (PROVIDING 75% OF O2) AND HEPATIC ARTERY (25%)

Question 6

WHAT IS NORMAL PORTAL VENOUS PRESSURE AND WHY IS THIS IMPORTANT?

Answer 6

7-10MM HG. IF THIS PRESSURE RISES (DUE TO IMPAIRED OUTFLOW OF BLOOD FROM LIVER…AND BLOOD BACKS UP) ASCITES OCCURS WHEN PROTEIN RICH FLUID IS PUSHED INTO ABDOMINAL CAVITY.

Question 7

WHAT IS THE MAJOR AUTOREGULATORY MECHANISM OF THE LIVER?

Answer 7

A DECREASE IN PORTAL VEIN BLOOD FLOW IS ACCOMPANIED BY AN INCREASE IN HEPATIC ARTERY BLOOD FLOW. THIS IS CALLED (HABR) HEPATIC ARTERY BUFFER RESPONSE. ALL VA DISRUPT THIS COUPLING…ISO THE LEAST.

Question 8

WHAT IS THE BEST VA TO USE IN LIVER FAILURE PATIENTS AND WHY?

Answer 8

ISO BECAUSE ITS LEAST DISRUPTIVE TO THE AUTO-REGULATORY COUPLING THAT DELIVERS OXYGENATED BLOOD TO THE LIVER VIA PORTAL VEIN AND HEPATIC ARTERY.

Question 9

PHYSIOLGICALLY WHAT WOULD MAKE THE LIVER HOLD MORE BLOOD (UP TO 1 L MORE)??

Answer 9

IF THE RAP INCREASES….SO THAT BACK PRESSURE DEVELOPS.

Question 10

WHAT HAPPENS TO THE BILE PRODUCED IN THE LIVER BETWEEN MEALS WHEN THE TONE OF SPHINCTER OF ODDI (DRAIN INTO STOMACH ) IS HIGH?

Answer 10

ITS DIVERTED TO THE GALL BLADDER FOR STORAGE. FAT IN THE STOMACH IS A TRIGGER FOR CHOLECYSTOKININ RELEASE WHICH CAUSES THE GALL BLADDER TO EMPTY.

Question 11

WHAT ARE THE 3 COMPONENTS OF BILE?

Answer 11

BILE SALTS, BILIRUBIN AND CHOLESTEROL.

Question 12

HOW DOES THE LIVER EXCRETE DRUGS AND WASTE?

Answer 12

BILE. THIS IS EFFECTED BY HEALTH OF LIVER ITSELF AND BLOODFLOW TO THE LIVER.

Question 13

WHAT IS CIRRHOSIS?

Answer 13

A SCARRED LIVER WHICH BECOMES FIBROTIC. THUS THE PORTAL PRESSURE INCREASES (CAUSING PORTAL HTN AND DECR. BLOOD FLOW) …THE HEPATIC ARTERY FLOW INCREASES TO COMPENSATE…BUT TOTAL HEPATIC BLOOD FLOW STILL DECREASES.
ALSO-THE PLT REMAIN IN THE SPLEEN.
S/S: ENLARGED SPLEEN/LIVER, ASCITES, JAUNDICE, WEAK, ESOPHAGEAL VARICES, N/V, ENCEPHALOPATHY, AND ABD PAIN.

Question 14

WHAT ARE THE 3 MAIN COMPLICATIONS FROM CIRROSIS?

Answer 14

HEMORRHAGE OF VARICES FROM PORTAL HTN.
ENCEPHALOPATHY/COMA
ASCITES/ HEPATORENAL SYNDROME

Question 15

WHAT DOES THE CV SYSTEM LOOK LIKE WITH CIRROSIS PT?

Answer 15

HYPERDYNAMIC. HIGH VOLUME OF THIN BLOOD. INCR. CO.

DECREASED SVR…INCREASED GLUCAGON (WHICH VASODILATES) LESS RESPONSE TO CATACHOLAMINES.

CHF.

Question 16

WHAT IS TREATMENT OF VARACIS FROM CIRRHOSIS?

Answer 16

B BLOCKER TO DECR. PORTAL VENOUS PRESSURE.
VASOPRESSIN
SCLEROTHERAPY. INJECTION INTO VARICES TO DECREASE THEM.
BLAKEMORE TUBE TO TAMPONADE
TIPS TO SHUNT BLOOD…SO LESS GOES THROUGH LIVER.
OR DSRS TO SHUNT SMALL AMT OF BLOOD.

Question 17

SUMMARIZE RESPIRATORY CHANGES ASSOCIATED WITH CIRRHOSIS….

Answer 17

O2/HGB SHIFT TO RIGHT

INCREASED CLOSING VOL, DECR. FRC.

Question 18

WHAT ARE THE 2 MAIN BLOOD COAGULATION STUDIES WE LOOK AT WITH LIVER FAILURE AND WHAT DO THEY MEAN?

Answer 18

WILL LIVER DX YOULL SEE:
DECREASED ALBUMIN
PROLONGED PT

Question 19

WHAT IS THE GOAL IN REDUCING ENCEPHALOPATHY AND WHY?

Answer 19

DECREASE AMMONIA CONCENTRATION BY DECREASING THE AMOUNT OF PROTEIN THE BLOOD BREAKS DOWN. SO STOP ANY BLEEDING, DECREASE PROTEIN INTAKE, DECREASE BACTERIA AND GIVE LACTULOSE.

Question 20

DO YOU NEED TO BE CAREFUL OF SEDATING PTS WITH LIVER FAILURE?

Answer 20

YES! D/T ENCEPHALOPATHY AND DECR LOC….LOOSE AIRWAY! CONSIDER SEDATING WITH ETOMIDATE.

Question 21

WHAT IS HEPATO-RENAL SYNDROME AND WHY DOES IT HAPPEN. HOW DO YOU TREAT?

Answer 21

THE KIDNEYS ARE HYPOPERFUSED. THE PT LOOKS HYPOVOLEMIC WITH INCR BUN/CR., DECR U/O ….BUT THERES STILL INCR ECF/EDEMA/ASCITES D/T NO SODIUM. TREAT WITH DENVER SHUNT AND DOPAMINE.

Question 22

WHAT IS HEPATITIS AND S/S?

Answer 22

INFLAMATION OF LIVER DUE TO VIRUS.
S/S: DARK URINE, DEHYDRATED, FATIGUE, ANOREXIA.
TREAT SYMPTOMS.

Question 23

WHAT ARE THE ONLY 2 ROUTINE TESTS THAT DIRECTLY ASSESS HEPATIC FXN?

Answer 23

PT AND ALBUMIN.

PT: NORM= 11-14. LOOKS AT CLOTTING ABILITY ….PROTHROMBIN, FIBRINOGEN, FACTORS 5 7 10.
CAN GIVE VIT K…REQUIRES 24 HR CORRECTION.

Question 24

WHAT WILL AST AND ALT LOOK LIKE IF YOU HAVE VIRAL HEPATITIS?

Answer 24

THEY WILL BE ELEVATED. THEY INCREASE 2 WKS BEFORE JAUNDICE APPEARS.

Question 25

WHAT IS MELD SCORE?

Answer 25

SCORING SYSTEM TO CLASSIFY SEVERITY OF LIVER DISEASE…..TO PRIORITIZE TRANSPLANT RECIPIENTS.
>40 71 % MORTALITY
< 9 1% MORTALITY

Question 26

WHAT DOES INDUCTION OF LIVER PT LOOK LIKE?

Answer 26

TREAT AS FULL STOMACH D/T ASCITES. RSI WITH ETOMIDATE TO PRESERVE CARDIAC. DECREASE DOSAGE OF DRUGS ESP. BENZO AND OPIATES. DECREASED PSEUDOCHOLINESTERASE SO PROLONGED SUX EFFECT.
CONSIDER HYPERDYNAMIC CARDIAC STATUS AND RESISTANCE TO CATACHOLAMINES. AVOID ESPOPHAGEAL MANIPULATION. NEED INVASIVE MONITORING. USE ISO. BEST MR CHOICE IS NIMBEX. LG BORE IV. REPLACE LOSSES WITH COLLOID.

Question 27

WHAT IS CHOLESTASIS AND HOW TO TREAT?

WHAT ARE ANESTHESIA CONSIDERATIONS?

Answer 27

REDUCTION OF BILE SECRETION FROM LIVER USUALLY DUE TO OBSTRUCTION OF THE BILIARY TRACT. TREAT: ERCP WHERE BILE DUCTS ARE VISUALIZED. PT IS PRONE AND HAS ASPIRATION RISK SO GETA IS BEST OVER MAC. MAY SEE: DECR. RESPONSE TO CATACHOLAMINES, VIT K DEFICIENCY, DECR. GFR.

Question 28

WHAT IS A COMMON TX FOR PANCREATIC TUMOR AND WHAT ARE ANESTHESIA CONSIDERATIONS?

Answer 28

WHIPPLE. TREAT AS LG ABD CASE WITH CVP, ART. LINE IV X2, FULL CARDIAC WORKUP, INTUBATED POST OP, EPIDURAL FOR POST OP PAIN.