Liver Disease

Question 1

Cholecystectomy Induction/Maintenance

Answer 1

Consider volume, e-lyte replacement
RSI with cricoid pressure, cuffed tube

Reverse tburg
Mechanical ventilation
Judicious use of opioids

Question 2

Cholecystectomy and opioids

Answer 2

Sphincter of Oddi spasm occurs in 3% of the population

Antagonize spasm with: Naloxone (maybe not the best idea). glucagon, NTG

Question 3

Volatile anesthetics and hepatic dysfunctions

Answer 3

VA produce a self-limiting post-op liver dysfunction- transient increase in alpha-GST

Halothane hepatitis:
Immune mediated
1 in 10,000-30,000
Only Sevo does not metabolize into trifluoroacetylaed compounds

Question 4

In case of post-op hepatic dysfunction

Answer 4

Review all drugs given
Check for sepsis
Check bilirubin
Rule out occult hematomas
Review peri-op record

Question 5

What is hepatitis

Answer 5

Liver disorder of varying etiology that results in inflammation and necrosis for more than 6 months

Question 6

Common hepatitis causes

Answer 6

HBV, HDV, HCV, autoimmune, drug induced

Graded on degree of inflammation, necrosis, progression, and degree of fibrosis

Question 7

Anesthesia for hepatitis

Answer 7

How long has the hepatitis been present
What stage is it
What type/mode of transmission
Signs/symptoms the pt is experiencing

Is patient optimized for anesthesia (fluids, e-lytes)
Does everyone have proper vaccines in place?

Question 8

Pre-op considerations in hepatitis

Answer 8

Coags?

Encephalopathy?

Question 9

Induction for hepatitis

Answer 9

NPO?
Volume status (often hypovolemic)
Other organ system involvement

Question 10

Viral hepatitis

Answer 10

5 types- HAV, HBV, HCV, HDV, HEV
C most common blood borne infection in US
D can only infect if the pt already has B
E for enteric transmission in Asia, Africa, Central America

S/S- anorexia, N/V, low grade fever, dark urine, clay colored stool, jaundice, acute liver failure

AST/ALT 400-4000

Question 11

Hep B Tx

Answer 11

Interferon, Lamivudine, Adefovir

Question 12

Hep C Tx

Answer 12

Interferon, Ribavirin

Question 13

Autoimmune hepatitis Tx

Answer 13

AZT, corticosteroids

Question 14

What is cirrhosis

Answer 14

Affects 3 million in US, 12th leading cause of death
Mostly due to ETOH and Hep C
Alters all organ systems in advanced stages

Question 15

Liver synthesizes all coag factors except

Answer 15

vWF

Question 16

Liver blood supply

Answer 16

Hep. artery gives 25% flow and 50% oxygen

Portal vein gives 75% flow and 50% oxygen

Question 17

Cirrhosis s/s

Answer 17

Fatigue
Anorexia
N/V
Abd. pain
Jaundice
Hypoalbuminemia
Coag problems
Endocrine dysfunction
Hepatic encephalopathy
Esophageal varices
Hepatomegaly/ascites

Question 18

CV function in cirrhosis

Answer 18

Hyperdynamic circulation
Increased CO
Normal ABP, filling pressures, HR
Possible cardiomyopathy
Decreased response to catecholamines
Increased flow to splanchnic, pulm, muscular, cutaneous beds
Decreased hepatic flow
Portal HTN
Arterial hypoxemia

Question 19

Pre-op cirrhosis

Answer 19

Treat as full stomach
Low albumin, decrease doses
Ascites, fluid status
Cardiomyopathy
PaO2 60-70 (R->L pulm shunt)
Hypoglycemia
Pneumonia
Encephalopathy
Hepatorenal syndrome

Question 20

Coagulation in cirrhosis

Answer 20

Prolong PT/INR
Vit K deficiency, factors II, V, VII, IX, X deficiency
Thrombocytopenia common
Bleeding accounts for 60% of deaths in abd. surg
Platelets 3 contraindications to elective surg

Need FFP, Vitamin K, Platelets

Question 21

Monitors for cirrhosis

Answer 21

CVP, A-line, +/- PA
UOP- foley

Blood glucose

AVOID esophageal temp probe

Question 22

Pre-op/Induction cirrhosis

Answer 22

volume status
RSI
Protein binding
ETOH on board?
Cardiomyopathy
Consider vitamin K, FFP, Platelets
Administer glucose solutions

Question 23

Maintenance cirrhosis

Answer 23

Avoid halothane, disrupts hepatic blood flow
Decrease in BP will decrease portal vein flow
Combine IA with N2O and opioids
Avoid pancuronium, succinylcholine/mivacurium/cis/atracurium OK
Increased Vd

Question 24

Post-op cirrhosis

Answer 24

Increased post-op morbidity-
Pneumonia
Bleeding
Sepsis
Poor wound healing
Liver dysfunction
DTs

Question 25

DTs

Answer 25

6-8 hours of ETOH withdrawal, pt may become tremulous
WIthin 24 hours hallucinations, grand mal seizures may occur
DTs within 72 hours
Treat with benzos

Question 26

Porphyria

Answer 26

Defective enzyme leads to overproduction of porphyrin

Acute intermittent porphyria is most serious

Question 27

Porphyria Tx

Answer 27

Remove trigger
Hydrate
Carbohydrates
Treat pain, N/V
BB for HTN, tachycardia
Benzos for seizures
Fluid and e-lyte balance

Hematin 3-4 mg/kg IV, somatostatin, plasmapheresis

Question 28

Triggers in porphyria

Answer 28

Allyl group barbs
Steroid structure drugs
Pentathol, thiamylal, methohexital, etomidate

Hormonal fluctuations, fasting, dehydration, stress, infection

Question 29

Anesthetic management in porphyria

Answer 29

Avoid known triggers, minimize use of multiple drugs
Minimize stress
Ensure proper hydration, use glucose solution

Give anxiolytics
Cimetidine decreases heme consumption and inhibits ALA synthetase (good)