Liver failure/CABG/ESRD

Question 1

MELD score

Answer 1

used to prioritize organ allocation to adult pts
NBC-I
Na, bili, Cr, INR

Question 2

platypnea

Answer 2

dyspnea worsening in the upright position

Question 3

hepatopulmonary syndrome

Answer 3

liver disease
decrease oxygenation (PaO2 < 70)
intrapulm vascular dilation (pulm angio, perfusion lung scan)

Question 4

dyspnea in End stage liver disease

Answer 4

heptopulm syndrome
pleural edema
alcoholic cardiomyopathy
cirrhotic cardiomyopathy
2/2 smoking or COPD
or a combo

Question 5

perks of paracentesis preop

Answer 5

-inc cardiac output (relieves compression on IVC)
-improved pulm gas exchange (inc pulm compliance, dec V/Q mismatch)
-dec risk of aspration (stomach compression)
**ensure adequate volume expansion w/ colloids

Question 6

Diagnosis of hepatorenal syndrome

Answer 6

1. presence of advc liver dx and portal HTN
2. lower GFR Cr > 1.5 or GFR < 40
3. absence of shock, infxn, fluid loss, or nephrotoxic agents
4. no sustained improvement in renal function w/ administration of fluids/albumin
5. no proteinuria, urinary obstruction or parenchymal renal dx

Question 7

pathophysiology of hepatorenal syndrome

Answer 7

portal HTN -> relase of vasodilators substances (nitric oxidee) -> splanchnic arterial vasodilation -> activation of the renin-angiotensin-aldo system -> inc absorption of water and Na and kidney vasoconstriction -> contuined decreased perfusion to kidneys

Type I: rapidly progressive w/i 2 weeks
type II: slower onset

Question 8

Meds to help w/ hepatorenal syndrome while waiting for transplant

Answer 8

albumin (volume expander)
midodrine (vasoconstrictor)
octreotide (inhbits splanchnic vasodilation)

Question 9

moderate pulm HTN

Answer 9

35-45

Question 10

pulm HTN

Answer 10

> 25

Question 11

pulm pressure CI to liver transplant

Answer 11

> 50

Question 12

Concerns w/ hepatic encephalopathy and anesthesia

Answer 12

-hypoK: can inc production of ammonia, make it worse
-maintain normal pH -> alkalemia can inc diffusion of ammonia across BBB
-correct hypovolemia or anemia: optimize liver metabolism of circulating toxicns
-careful w/ benosz: suppresion of CNS can exacerbate his condition

Question 13

pathophysiology of hepatopulmonary syndrome

Answer 13

portal hypertension -> hyperdynamic circulation and fluid overload -> splanchnic volume overload and bowel edema -> bacterial translocation and cytokine activation -> inc activation of macrophages in lungs -> inc/accumulation of nitric oxide to promote vasodiatlion w/ accumulation of MP -> abnormal pulmonary dilation and blunting of HPV

Question 14

Goals for coags preop in end stage liver dx

Answer 14

plts > 50-60,000
INR < 1.5
no signs of active bleeding

Question 15

veno-veno bypass in liver transplant

Answer 15

femoral and portal veins are cannulated to reroute blood flow from below the diaphragm to the suprahepatic vena cava (axillary, subclavian or jugular vein)
-minimizes interruption of caval flow from anhepatic phase
-adv: improved cardiac filling, dec blood and fluid requirements, improved surgical field
-disadv: inc risk of air embolism, thromboembolism, arm lymphedema, hematoma, vascular/n inury

Question 16

succinylcholine and end stage liver dx

Answer 16

-can use due to inc risk of aspiration to secure airway as soon as possible
-however maybe prolonged due to reduced production of pseudocholinesterase
(FFP provides additional pseudocholinesterase)

Question 17

stages of liver transplant

Answer 17

preanhepatic: liver dissected and mobilized until only attached by IVC, portal vein, hepatic a, and CBD
-anhepatic phase: clamping of the hepatic artery, until implantation of new liver
-post-anhepatic phase: reperfusion to completion of surgery

Question 18

start of anhepatic phase, surgeon clamps IVC BP dec to 78/44, what to do?

Answer 18

-communicate w/ surgeon, have them release the clamp -> hypoTN most likely due to dec preload
-also can be other causes: FiO2 100%, auscultate lungs, verify ETT placement, give fluids and vasopressors
-discuss w/ surgeon possibility of veno veno bypass -> if not fluids and ensure presence of vasopressors

Question 19

anhepatic peaked T waves widened QRS, what’s going on

Answer 19

hyperK: combo of acidemia w/ clamping, dec UOP of K, reduced hepatic uptake of K, K in blood produces, and K containing solution
-order a K level, let surgeon know, and start treatment
-give calcium, ensure access to cardiac defibrillator, correct acidosis, hypocalcemia, give insulin and glucose, albuterol, and bicarb
-hyperventilate
-consider HD if insufficient

Question 20

hypoCa under GA

Answer 20

widened QRS complexes
hypoTN
narros pulse pressure
prolonged QT
elevated CVP
flattened T waves

Question 21

Treatment of hypoCa w/ citrate toxicity

Answer 21

give calcium chloride or gluconate
-correct hypothermia
-tx hypoTN and arrhythmias

Question 22

hypoTN at beginning of reperfusion w/ liver transplant

Answer 22

removal of vascular clamps w/ postperfusion syndrome -> hypoTN, bradycardia, arrhythmias, elevated pulm a pressures
-hemorrhages, tension PTX, CHF, hyperK

Question 23

What causes reperfusion syndrome

Answer 23

excessive K in graft
release of vasoactive substances and acidic metabolites from graft and lower extremities
cold blood from graft
cytokines

Question 24

how to reduce reperfusion syndrome

Answer 24

careful flushing of graft before reperfusion
give bicarb
correct metabolic acidosis
calcium
inotropes or vasoconstrictors

Question 25

potential postop complications w/ liver transplant

Answer 25

-bleeding varices
-vascular anastomic leake
-coagulopathy (DIC, residual heparin, dilution coagulopathy)
renal dysfxn
CHF
TRALI
pulm edema
biliary complications
hepatic or portal vessel thrombosis
encephalopathy
peripheral n injury
infxn
graft failure or rejection