Liver/Bili

Question 1

most common cause of cholestasis and treatment

Answer 1

obstruction of the biliary tract outside the liver (gallstones, strictures, infection, or ischemia)
cholecystectomy

Question 2

temporary treatment for acute cholecystitis

Answer 2

decompression and drainage of the gallbladder w cholecystectomy tube

Question 3

6 indications for cholecysectomy

Answer 3

symptomatic cholelithiasis, acute cholecystitis, chronic cholecystitis, biliary dyskinesia, GB polyps or carcinoma, choledocholithiasis

Question 4

what is cholangiography

Answer 4

cystic duct is opened and dye is injected into the biliary tree and xrays are taken to identify stones or abnormalities –> CBD exploration to ERCP performed if needed

Question 5

respiratory considerations with CBD surgery (pre-op)

Answer 5

-pain –> reduced FRC, hypoventilation, atelectasis, tachypnea, respiratory alkalosis
-sepsis –> tachypnea & respiratory alkalosis

Question 6

CV considerations for GB sx

Answer 6

-hypovolemia (vomiting, reduced PO intake) –> resuscitate
-exaggerated effects with reverse Trend + insufflation (impaired venous return)
-epigastric discomfort can mimic MI

Question 7

GI considerations for GB sx

Answer 7

-peritonitis, abdominal distension, paralytic ileus
-consider full stomach RSI
-if n/v check electrolytes

Question 8

what is the sphincter of oddi

Answer 8

smooth muscle that surrounds the end of the CBD and pancreatic duct and allows bile to flow into the small intestine during digestion

Question 9

what meds and conditions can cause sphincter of oddi to spasm

Answer 9

opioids
acute cholecystitis (raises GB intraluminal pressure)

Question 10

what medication is the treatment for sphincter of oddi spasms

Answer 10

glucagon 0.5-1mg per surgeon request
–reduces intraluminal pressure of the GB

Question 11

what is an ERCP

Answer 11

-easiest and least invasive way to enter the bile duct to diagnose and treat conditions of the liver, bile duct, and pancreas (stones or stenosis). can relieve obstruction of bile/panc ducts

Question 12

Respiratory considerations for ERCP

Answer 12

-airway eval and assess the need for GETA
-may have limited access to the airway intra-procedure
-if ascites and pleural fluid accumulation –> impaired ventilation and increased aspiration risk

Question 13

CV considerations for ERCP

Answer 13

hypotension and ECG changes are common

Question 14

hepatic considerations for ERCP

Answer 14

coagulopathy, altered drug metabolism, and other metabolic disturbances

Question 15

renal considerations for ERCP

Answer 15

may have ARF (high BUN/Cr) due to volume depletion

Question 16

in what case may volume depletion be severe and require resuscitation pre-op

Answer 16

acute pancreatitis

Question 17

whta type of anesthesia is used for ERCP

Answer 17

deep sedation vs GA (if complex, high asp risk, or uncooperative, +/- RSI)

Question 18

Anesthetic Considerations for ERCP
-position
-access
-ETT
-GI
-other

Answer 18

-prone with head turned, arms by side
-1 PIV, +/- art line
-risk for R mainstem or extubation by scope
-decompress the stomach
-place bit block and have glucagon available

Question 19

what is the most important predictor of short-term survival s/p hepatic resection

Answer 19

intra-op blood loss

Question 20

where does bleed occur from during hepatic resection

Answer 20

intrahepatic branches of portal and hepatic veins

Question 21

anatomic vs non-anatomic liver resections

Answer 21

anatomic =veins/arteries dissected and mobilized before resection of liver parenchyma.
non-anatomic= only the tumor w 1-2cm margin is removed, not the entire lobe or segment (good for cirrhosis or chronic hepatitis)

Question 22

CV/resp liver resection pre-op considerations

Answer 22

-Ascites effect on respiratory mechanics
- tumor size and location may impede venous return
-anticipate high EBL

Question 23

what does the liver produce? except?

Answer 23

-all clotting factors ex factor 8
-have coags and T&S

Question 24

Anes for liver resection:
-anes
-lines
-position
-EBL & tx

Answer 24

-GETA/RSI/epidural
-2 PIV, art line, foley, +/- CVC & TEE
-supine
-250-750 –> IVF, albumin, blood

Question 25

liver resection: elevated CVP to what

Answer 25

-12mmHg prior to X-clamping

Question 26

liver resection: expect what after major resections and treat with?

Answer 26

-major HD changes
-phenylephrine and epi for hypotension

Question 27

anesthetic plan for liver sx blood loss

Answer 27

NS 10-20ml/kg/hr
T&S
2uPRBC ready
be prepared for MTP (PRBC, FFP, plt, Ca)
blood salvage devices

Question 28

CVP strategy for blood loss and liver sx

Answer 28

-intermittent vascular inflow occlusion or total vascular occlusion
-CVP < 5mmHg prevents liver congestion and reduces bleeding, increasing the risk of ARF
-CVP 7-10 = increased bleeding and transfusion rate

Question 29

pringle maneuver

Answer 29

-a method to control intra-operative blood loss
-temporary occlusion of the hepatoduodenal ligament
-usually tolerated for 15-20min
-rarely used today bc of newer techniques

Question 30

what 3 structures are occluded by occlusion of the hepatoduodenal ligament in the pringle maneuver

Answer 30

portal vein, hepatic artery, and CBD

Question 32

laparoscopic liver resection management tips to reduce blood loss

Answer 32

CO2 pneumo to 10-14mmHg
lower CVP <5