Liver

Question 1

What increased unconjugated bilirubin means

Answer 1

Inc bilirubin production, decreased hepatic uptake, or decreased conjugation

Question 2

What increased conjugated bilirubin means

Answer 2

Decreased canalicular transport of bilirubin, acute/chronic hepatocellular dysfunction, obstruction of bile ducts

Question 3

What ALT and AST are representative to

Answer 3

ALT- liver. AST- liver and extrahepatic tissues

Question 4

Alkaline phosphatase represents what. Lacks what. Which most specific to biliary damage

Answer 4

Inc levels may mean inc bile salts and induced damage of hepatocytes membranes. Lack specificity. 5’NT

Question 5

INR indicates what

Answer 5

Strong correlation w declining hepatic func. Predictive value for survival, used in child Pugh score. Hepatic synthesis of clotting (vitamin K) factors

Question 6

Pre hepatic dysfunction: what happens to LFTs and causes

Answer 6

Bilirubin (inc unconjugated). AST/ALT and alk phos normal. Hemolysis, hematoma absorption, bilirubin overload

Question 7

Intrahepatic dysfunction: what happens to LFTs and causes

Answer 7

Inc conjugated, inc AST/ALT, normal/inc alk phos. Viral infec, drugs, etoh, sepsis, cirrhosis

Question 8

What posthepatic dysfunction labs look like and causes

Answer 8

Inc conjugated bilirubin, normal/inc AST/ALT, inc alk phos. Biliary stones or sepsis

Question 9

Acute cholecystitis. Occurs most often in who. Symp

Answer 9

Women, fair, inc age, obese, rapid wt loss, pregnancy. NV, fever, RUQ pain (radiating to back), dark urine, sclera icterus

Question 10

What insufflation of abd does to vent and cv systems

Answer 10

Inadequate vent. Dec venous return/CO, inc MAP and SVR. Bradycardia.

Question 11

Risks w laparoscopic procedure

Answer 11

Vascular injury, blood loss, co2 embolism

Question 12

Consid for lap Chloe procedure

Answer 12

Vol/lyte replacement pre op. RSI. Watch PIP/MV. Support BP and HR. NGT. No Nitrous oxide. Opioids may cause oddi spasm, tx w glucagon/narcan/ntg

Question 13

What causes drug induced hepatitis. What happens.

Answer 13

Analgesics, anticonvulsants, abx, antihypertensives. APAP exhausts glutathione stores, unable to conjugate. Build up of n acetylcysteine

Question 14

Halothane hepatitis- cause, mediation, sensitized ppl show what

Answer 14

Trifluroacetyl halide metabolites bind w proteins on hepatocytes, change them to not self. IgG mediated. Cross reactivity w other VA except for sevo

Question 15

What cirrhosis labs look like

Answer 15

Inc bilirubin, aminotransferase, alk phos, INR. Dec albumin, plt BG

Question 16

Child Pugh score. Used for what. Components. Mortality

Answer 16

Predicts surgical mortality w cirrhosis. Total bili, albumin, INR, ascites, hepatic encephalopathy. A- 10% mort w intraabdominal sx. B- 30% mortality. C- 80% mortality (delay sx)

Question 17

Anesthesia consid encephalopathy

Answer 17

RSI, careful use of sedatives/induction agents

Question 18

Anesthesia consid ascites

Answer 18

RSI, mech vent, PFTs, PA pressures, fluid status

Question 19

Esophageal varicies anesthesia consid

Answer 19

No esophageal temp probe. If bleeding, RSI. Ocreotide 50 mcg/hr or vaso 20 u over 5 min

Question 20

Anesthesia consid for hyperdynamic circ

Answer 20

Dec SVR and inc CO. Avoid direct myo depressants, place invasive monitors, replace fluids, give neo/NE/vaso. Impaired response to catecholamines

Question 21

Anesthesia consid for coagulopathy

Answer 21

T/C. Vit K non emergently. Only factors not made by liver are 3, 4, 12. Unable to handle citrate in PRBCs, monitor calcium/replace. Give FFP/Cryo/Plt

Question 22

Pharmacokinetics

Answer 22

Dec protein binding and inc VD from low albumin. DEecreased clearance- inc initial NMB dose then less subsequent dose.

Question 23

NMB not cleared by liver

Answer 23

Cis atra, atra, miva

Question 24

Causes of post op morbidity w cirrhosis

Answer 24

Liver dysfunc/failure, pna, bleed, sepsis, poor wound healing, DTs, lyte disturbance, renal failure

Question 25

Anes consid w alcoholism

Answer 25

Chronic- inc anesthesia reqs. Acute- dec anesthesia Recs. If acutely intoxicated- RSI.

Question 26

Etoh withdrawal s/s

Answer 26

Inc SNS/catecholamines, inc HR, agitated, DTs 48 h after, halluc, dysrhythmias, seizures, low BG

Question 27

Tx etoh withdrawal

Answer 27

Benzos, BB (propranolol or esmolol), a/w protection, correct fluid/lutes

Question 28

Acute intermittent porphyria implic

Answer 28

Most serious. Affects CNS and PNS. Htn and renal dysfunc. Can be life threatening

Question 29

Porphyria triggers

Answer 29

Allyl group on barbs, steroid structure. Avoid thiamylal, methohexital, and etomidate. Menstruation/menopause/preg, fasting, dehyd, stress, infec

Question 30

Porphyria s/s

Answer 30

Abd pain, NV, ANS instability, Na/K/Mg imbalance, muscle weakness, resp failure, htn, tachycardia, seizures

Question 31

Tx porphyria

Answer 31

Remove trigger. Hydrate, carbs, tx pain and nv, bb for htn/tachy, benzos for seizures, fluid and lyte balance, hematin 3-4 mg/kg, somatostatin, plasmapheresis

Question 32

Anes manage porphyria

Answer 32

Avoid trigger drugs. Assess skeletal and CN func. Tx htn and tachy. Fluid and lute. Anticipate post op vent. Give glucose and saline. Pre op anxiolytics and cimetitidine (asp prophylaxis)

Question 33

Regional consid w porphyria

Answer 33

Neuro eval. May lead to cv instability if hypovolemic. Avoid in acute exac

Question 34

General consid porphyria

Answer 34

Short acting agents. Propofol or ketamine. Maintain w N20/VA/opioids/NMBs.

Question 35

Safe drugs prophyria

Answer 35

Opioids, propofol, ketamine, ASA, pcn, glucocorticoids, insulin, atropine/glyco, neostigmine, LAs, cv drugs, IAs, NMBs

Question 36

Unsafe drugs w porphyria

Answer 36

Barbs, etomidate, sulfonamide abx, etoh, diazepam, nifedipine, ketorolac, phenacetin