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Principles 2 > Liver Anesthesia Mgmt & Surgeries > Flashcards

Liver Anesthesia Mgmt & Surgeries Flashcards

1
Q

What does sympathetic activation due to the hepatic blood flow?

A

Vasoconstriction of hepatic artery leads to decreased hepatic blood flow.

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2
Q

What does Beta Adrenergic stimulation due to hepatic blood flow?

A

Vasodilation of the hepatic artery leads to increased hepatic blood flow.
-Beta Blockers decrease blood flow.

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3
Q

What are the effects of General Anesthesia on the Liver?

A

-Reduction in blood flow (dec CO and dec MAP)
-Volatiles: Isoflurane is the best option for a liver case

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4
Q

What are the effects of Regional Anesthesia on the Liver?

A

-Likely not doing RA on these patients due to bleeding issues
-Sympathectomy affects Splanchnic circulation (Liver, GB, omentum, spleen, and pancreas)
-Spinal nerves T3-T11
-Reduced splanchnic blood flow

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5
Q

How do the different volatiles affect Liver function?

A

-Isoflurane increases hepatic blood flow through direct vasodilatory properties
-Desflurane has similar effects to isoflurane, but is more expensive. Can lead to more HD instability.
-Sevoflurane undergoes hepatic biotransformation, producing organic and inorganic fluoride ions (generally below nephrotoxic levels). No significant clinical toxicity is reported with Sevo

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6
Q

How does the surgical site affect liver function?

A

-Upper abdominal surgical sites can cause decreased hepatic blood flow
-Traction on the abdominal viscera may cause reflex dilation of splanchnic capacitance vessels and thereby lower hepatic blood flow.

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7
Q

How does mechanical ventilation effect liver function?

A

Increased airway pressures:
-Decrease venous return
-Reduce CO

PEEP: further reduces venous return. Not recommended to use if you’re having HD instability due to reduction in venous return.

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8
Q

How do opioids affect Liver function?

A

-Opioids cause spasm of the Sphincter of Oddi
-Sphincter of Oddi is what allows flow of bile and pancreatic secretions into the duodenum
-Spasm = obstructed flow = increased pressure between bile duct and duodenum.

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9
Q

What should be assessed on the pre-op evaluation of a patient with liver disease?

A

Physical signs:
-Jaundice
-Petechiae
-Ascites
-Dependent edema
-Altered Mental Status
These suggest significant liver disease is present.

Labs:
Albumin
CBC
Coagulation studies
BMP
BUN
Cr
Glucose
ALT & AST
T&S, cross-match

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10
Q

What is important to know regarding laboratory testing of liver function?

A

-No single lab test to assess liver function
-Huge functional reserve: Significant disease before seen clinically (Liver will compensate for awhile)

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11
Q

What is indicated by the AST/ALTs?

A

Destruction at the parenchymal (tissue) of the Liver
-AST: NOT specific to Liver
-ALT: Liver specific. Signifies leakage coming from damaged hepatocytes.

Obstructive disorders are detected by Alk Phos

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12
Q

What is the Child-Pugh Score?

A

Scores the severity of Liver Disease.
Calculated by adding the points based on the five features:
-class A = 5 or 6
-class B = 7–9
-class C = 10 and higher.
The classes indicate the severity of liver dysfunction: Class A is associated with a good prognosis, and class C is associated with limited life expectancy.

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13
Q

What are the parameters assessed on the Child-Pugh Score?

A

Encephalopathy
Ascites
Bilirubin (mg/dL)
Albumin (g/dL)
PT (INR)

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14
Q

What values are “Low Risk” on the Child-Pugh Score?

A

1 point each.
-Encephalopathy: None
-Ascites: Absent
-Bilirubin: <2
-Albumin: >3.5
-PT/INR: <1.7

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15
Q

What values are “Moderate Risk” on the Child-Pugh Score?

A

2 points each.
-Encephalopathy: Moderate
-Ascites: Slight
-Bilirubin: 2-3
-Albumin: 2.8 - 3.5
-PT/INR: 1.7 - 2.3

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16
Q

What values are “High Risk” on the Child-Pugh Score?

A

3 points each.
-Encephalopathy: Severe
-Ascites: Moderate
-Bilirubin: >3
-Albumin: <2.8
-PT/INR: >2.3

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17
Q

What is the Model for End-Stage Liver Disease (MELD) Score?

A

MELD is a scoring system that assesses the severity of chronic liver disease. It is useful in prioritizing recipients for liver transplant, as it predicts the outcome based on the calculated score. MELD uses the patient’s values for serum bilirubin, serum creatinine, and the INR(PT) to predict three-month survival (interpretation of MELD score is given in).

If score is >/= 40, 100% mortality rate

18
Q

What is the pre-op anesthesia plan for a patient with Liver dysfunction?

A

-Pre-op sedation may be unnecessary if encephalopathy
-Huge aspiration risk due to impaired gastric motility. Need Reglan, Zantac, RSI
-Invasive monitors: Art Line and possibly PAC if monitoring for Pulmonary HTN with liver transplant

19
Q

What do you have to consider when using Regional Anesthesia in a patient with Liver dysfunction?

A

-Platelet and Coagulation status (No NA/RA if plts <100,000)
-Benzos, Barbs, and Opioids are highly protein bound = decrease the dose
-Theorized to have increased benzodiazepine receptors = decrease the dose

20
Q

What is the preferred induction for a patient with Liver dysfunction?

A

-RSI due to impaired gastric function and inc abdominal pressure from ascites
-Patients will be short of breath. Need reverse T burg and Cricoid pressure
-Succinylcholine may have prolonged DOA due to decreased plasma cholinesterase. Also risk with hyperkalemia and immobile/debilitated patients
-DOA of MR will be extended if hepatically cleared.
-Volatiles: Isoflurane is best

21
Q

Can you use N2O in a patient with Liver Dysfunction?

A

Avoid the use of Nitrous Oxide due to possibility of expansion of the bowel (bowel distention) and sympathomimetic effect causing hepatic vasoconstriction

22
Q

What are intra-op causes of Liver Hypoxia?

A

-Inadequate ventilation (Diaphragm is restricted by large belly. Need to get proper Vts)
-Excessive bleeding
-Hypovolemia (Intravascularly dry)
-Hypotension
-Inadequate C.O.
-* vasoconstrictive reduction in splanchnic blood flow

23
Q

What are your intra-op hemodynamic goals with the patient with Liver dysfunction?

A

To optimize central & systemic arterial perfusion pressures.
-Maintain C.O.
-Avoid arterial HOTN
-Minimal vasoconstrictive agents (1st line tx of hypotension is fluid)
-Adequate anesthesia
-Decrease surgically induced stress response (give fentanyl/precedex with incision)

24
Q

Are opioids appropriate for a patient with liver dysfunction?

A

-Opioids are dependent on hepatic metabolism, use caution
-Decrease the dose
-Remifentanil is a good choice (metabolized in the blood)
-Morphine is not appropriate

25
Q

Why is morphine not appropriate for use in a patient with Liver dysfunction?

A

It releases Histamine.

Nagelhout:
-Morphine is metabolized in a phase II reaction, undergoing glucuronidation in the liver, and should be titrated cautiously or avoided in patients with significant liver disease.

26
Q

What is Octreotide used for?

A

-Somatostatin analog
-Used to decrease venous return to portal circulation

27
Q

Why do you want to maintain normocarbia intrap?

A

To optimize oxygen extraction and optimize organ perfusion.

28
Q

Why do you want to avoid hypothermia in patients with liver dysfunction?

A

-Worsens coagulopathies
-2 forced air warming blankets
-Warm IVF

29
Q

What are the anesthetic concerns with an acutely intoxicated patient?

A

-They will have labile VS. try to keep things consistent.
-Aspiration precautions
-Brain is less tolerant of hypoxia
-Circulating catecholamines are increased (labile VS)
-Increased bleeding due to dysfunctional platelets.

30
Q

What are indications for a Liver resection?

A

-Carcinoma
-Trauma (Liver Laceration)
-Living Donor

The liver is unique, it can regenerate itself.

31
Q

When is Radiofrequency Ablation performed?

A

To non-resectable tumors.
-Can be done for palliative reasons
-Patients can range from healthy to super sick.
-Uses US to image where the tumor is.

32
Q

What is Irreversible Electroporation (IRE)?

A

-Used with hepatic resection, open and laparoscopic microwave ablation
-Locally treat advanced pancreatic/ liver tumors
-Alone or with resection
-Long needles (Antennas) are placed around the tumor and deliver high voltage DC current.
-Extremely painful during current delivery, but none after. (Anticipate this and medicate up front to save your emergence)

Location of tumor determines the pain.
-If they get around celiac plexus, may find HD instability occurring. Communicate with staff.
-If they are near the dome of the liver, there is a 10% chance of v tach occurring. Be ready for that.

33
Q

What is the anesthesia management of Irreversible Electroporation (IRE)?

A

-Need cardiac workup pre-op
-Full MR (0/4 twitches)
-Keep fully relaxed until the very end (bucking during electricity is bad)
-Remi gtt works well (0.5 - 2 mcg/kg/min)
-May see bradycardia when they start delivering high current

34
Q

What is a TIPS procedure?

A

Transjugular Intrahepatic Portosystemic Shunt.
-Right IJ→IVC →R hepatic vein →channel via liver parenchyma to portal vein
-Shunting high portal circulation directly to systemic circulation via a stent.
-Done under GA with patient relaxed
-Relieves portal back pressure, reducing esophageal varices bleeding and ascites.
-Palliative measure

35
Q

What are complications of a TIPS procedure?

A

-Liver puncture
-Hepatic Artery puncture (Remember that Hepatic Artery and Portal Vein are parallel)
-PE
-Encephalopathy because diverted blood does not undergo hepatic metabolic processes

36
Q

What is Chemoembolization?

A

-Sclerosing vessels to shunt blood to healthy vessels
-Cuts off blood supply to tumors before doing surgery to help with massive blood loss
-Usually GA
-Femoral artery to hepatic artery

37
Q

What is an ERCP?

A

Endoscopic Retrograde Cholangiopancreatography.
-Done in NORA
-Patient is prone
-Uses X-Ray
-Shared airway with gastroenterologist
-Very fast, can’t use a lot of MR. Can use succ or low-dose Roc.
-Go down esophagus with scope into stomach/duodenum, usually if you have a biliary stone. Place a stent to relieve obstruction.
-Need RSI due to risk of aspiration (bile filled gallbladder)

38
Q

Describe induction for a Liver Transplant.

A

-Drug metabolism & protein binding is effected
-Avoid hypoxemia due to ascites already causing decreased lung volumes due to diaphragm being unable to descend
-RSI due to aspiration risk from delayed gastric emptying
-Monitor PA pressures

39
Q

What are the 3 phases of a Liver transplant?

A

Dissection
Anhepatic
Reperfusion (neohepatic)

40
Q

Describe the Dissection phase of liver transplant?

A

-Mobilizing vascular structures around the liver. Dissect out the hepatic artery, portal vein, and vena cava
-Cardiac instability during this phase. Potential hemorrhage, venous pooling, impaired venous return, and issues with surgical retraction
-Drainage of ascites = massive fluid shifts

41
Q

Describe the Anhepatic phase of Liver Transplant

A

-Isolate common bile duct
-Remove native liver
-May need veno-venous bypass to maintain HD stability

42
Q

Describe the Reperfusion (Neohepatic) phase of Liver Transplant

A

-New liver is placed. Pay attention to the surgical field
-Will unclamp and reperfuse organ, may get some HD instability (has lactic acid building up in area - causes massive vasodilation)
-Reanastomosis of major vascular structures
-Allograft flushed: getting out air, debris, and preservative solutions
-HD instability: dysrhythmias, bradycardia, hypotension, and hyperkalemic arrest

Principles 2 (45 decks)

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