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SNRAObPedGer > Pediatric Hematology > Flashcards

Pediatric Hematology Flashcards

1
Q

When does liver started being produced?

A

3-4 weeks of gestation liver start

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2
Q

Fetal liver takes over RBC production at

A

6 weeks of gestation

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3
Q

BF shunted through______from Placenta to _______via _____

A

BF shunted through liver from placenta to RA via ductus venosus

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4
Q

• Dual blood source

A
  • Portal vein that drains spleen + intestine
    * >70% total BF
  • Hepatic artery
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5
Q

Blood flow

A

Blood goes through channels leading to a central vein →L/R hepatic vein → IVC

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6
Q

Kids have________hepatocytes compared to adults

• Cells 1/3 size of adults

A

20% fewer hepatocytes

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7
Q

STrutural unit of the liver is the

A

lobule

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8
Q

2 things that go in the opposite direction

A

Bile and blood

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9
Q

Functional unit of the liver is the

A

ACINUS

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10
Q

Functional unit = hepatic acinus
• Extends into
• __________most active in oxidative process

A

three zones; Central zones (1,2)

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11
Q

_________closest to central vein depends on glycolysis and most susceptible to ischemic/toxic injury

A

Distal zone 3

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12
Q

Hepatic metabolism

A

Transforms lipid-soluble drugs to water-soluble metabolite compounds that are easily excreted by kidney
•

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13
Q

• Primary liver enzyme =

A

cytochrome P- 450 (CYP)

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14
Q

Two primary reactions

A

• Phase 1 = Hydroxylation (via CYP450)
• Prepares drug for conjugation
• Phase 2 = Conjugation (glucuronidation, sulfation,
glutathione, acetylation)

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15
Q

CYP enzymes can be:

Examples

A

• Inhibited = compete for same enzyme

EXAMPLES: • Grapefruit juice, fluoxetine, quinidine, sulfaphenazole

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16
Q

Induced =

Examples

A

enhanced expression →faster drug breakdown
• Tobacco smoke, phenytoin, rifampin, CHRONIC ALCOHOLISM (great requirement for anesthesia)
carbamazepine, phenobarbital.

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17
Q

• CYP3A4 = most anesthetics

A

most abundant in human body, accounts for 50% of metabolism of clinically used pharmaceutical

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18
Q

Inhalation anesthetic metabolism

A

Undergo oxidative and reductive reactions

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19
Q

• Halothane broken down

A

(15-20%) to tri-fluoroacetyl →trifluoroacetic

acid (TFA) chloride

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20
Q

• Isoflurane metabolized

A

0.2% →TFA (Trifluoroacetic acid)

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21
Q

• Desflurane least metabolized

A

0.02% →TFA

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22
Q

• Sevoflurane metabolized

A

2-5% to formyl fluoride

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23
Q

Mnemonic to remember Metabolism from LEAST TO MORE METABOLIZED

A

DISH (0.02%–>0.2%–>2-5% –>15%)

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24
Q

Does not break down to to TFA

A

Sevoflurane

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25
Q

Liver issue patient

A

Give Sevoflurane

26
Q

Anesthetic agents : NMB drugs

A

Neuromuscular blocking drugs

• Plasma cholinesterase synthesized by liver

27
Q

• Hepatic elimination depends on

A

protein binding, hepatic BF, drug extraction

28
Q

• 75% of administered NMB bound to

A

plasma proteins

29
Q

• Volume of distribution________(inc/dec) with liver disease →

A

increased with ; lower concentrations

30
Q

• Peds c/cholestatic liver disease such as ________have ____uptake –> ___Plasma clearance + _____effects

A

(biliary atresia) have ↓uptake → ↓plasma clearance +

prolongs effects

31
Q

The more to the brain

A

the more effect it will have

32
Q

Greater VOLUME OF DISTRIBUTION

A

Specific one for each drug

Specific one for each patient

33
Q

Greater Vd give ____and _____maintenance dose

A

Greater BOLUS

Less maintenance dose.

34
Q

Obesity patients have

A

Increase Vd

35
Q

Sedatives including (3) are lipid soluble

A

Midazolam
Propofol
Ketamine

36
Q

Issue with ketamine

A

Give with something else Like versed

They can have bad dream remember DISSOCIATION

37
Q

Ketamine metabolized via –>

A

via methylation → clearance minimally affected by liver

dysfunction

38
Q

Opioids Clearance

A

• Hepatic clearance and protein binding determines serum concentration of an opioid

39
Q

Opioids: Most oxidized in________except (where)

Damaged li

A

liver (except remifentanil →plasma/tissue cholinesterases

• Damaged liver not as efficient → ↓first-pass effect/drug clearance

40
Q

First pass effect

A

Liver remove good majority of drugs for some drugs

41
Q

Fentanyl may get trapped in the

A

stomach

42
Q

(4) highly extracted by liver →

A

Meperidine, lidocaine, pentazocine, and morphine

perfusion limited clearance

43
Q

• Conditions that alter hepatic BF:

A 
cirrhosis, portal vein thrombosis,
portacaval shunting (blood shunted away from liver TIPS)
44
Q

• Methadone highly dependent

A

on enzyme capacity –>↑Half-life and volume of distribution

45
Q

Pharmacokinetics of ______ _____,______unchanged with significant hepatic dysfunction

A

fentanyl, remifentanil, and sufentanil

46
Q

Anesthetic Effects on Hepatic Cellular Function

A

Carbs

50% of glucose available to liver undergoes glycolysis, 30-40% converted to fat, 10-20% shunted to glycogen

47
Q

Most glucose production normally occurs in

A

liver

• Indirectly regulated by insulin

48
Q

Glycogen breaks down to produce

A

glucose

49
Q

Anesthesia inhibits glucose uptake by_________

A

hepatocytes

50
Q
  • All volatiles do this a little bit but______

* This effect and stress from surgery →

A

@ 1-2MAC inhibition up to 50%

hyperglycemia

51
Q

• Protein synthesis

•

A

May be inhibited (rat studies) by sevoflurane

• May affect albumin

52
Q

Drug-induced liver injury : Diagnosis

A

• ↑ alanine aminotransferase (ALT) (MOST ACCURATE for liver) and aspartate aminotransferase (AST) (liver enzymes
↑alkaline phosphatase, bilirubin, gamma-glutamyl transferase (GGT)

53
Q

Liver enzymes are POOR markers of liver

function, only suggest

A

drug-induced injury

54
Q

• Liver functions best detailed by

A

PT/INR

55
Q

• Consider also for liver injury?

A

hypoalbuminemia,
hypoglycemia
AMS too

56
Q

______ and _______can induce CYP2E1, which may facilitate development of liver injury

A

• Obesity and hypercholesterolemia

57
Q

Perioperative considerations for Liver patients

A

Assess for hepatocellular and bile duct injury, coagulopathy, ascites, and encephalopathy

58
Q

• Presence of (2) contraindications to elective

surgery

A

hepatopulmonary syndrome

portopulmonary HTN

59
Q

• ________ ______results in more death perioperatively than in cirrhosis

A

Acute hepatitis

60
Q

• Stress from surgery

A

↓portal circulation, liver disease can limit compensate via hepatic artery = ischemia

61
Q

Percentage of blood going to portal

A

30%

SNRAObPedGer (25 decks)

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