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Pathophys II > Hepatic Part 3 > Flashcards

Hepatic Part 3 Flashcards

1
Q

Preoperative considerations for the patient with acute hepatitis include

A

postpone elective surgery until resolved as determined by normal liver function test
-increased periop morbidity & mortality during acute phase

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2
Q

Perioperative considerations for patients with acute alcoholic hepatitis includes

A

risk with alcoholic hepatitis may not be as great

but patients could suffer from withdrawal during surgery and this is associated with a high mortality rate

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3
Q

Patients with hepatitis are at risk for further hepatic dysfunction and hepatic failure include

A

encephalopathy, coagulopathy, & hepatorenal syndrome

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4
Q

For patients who are chronic alcoholics, hypomagnesemia may occur

A

which predisposes to dysrhythmias

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5
Q

Lab evaluation of the patient with acute hepatitis includes

A

BUN, creatinine, bilirubin, electrolytes, glucose, transaminases, alkaline phosphatase, albumin, prothrombin time (INR), platelet count
serum HBsAg
blood alcohol level

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6
Q

Elevated transaminases do not

A

correlate well with the degree of cellular necrosis

bilirubin & alkaline phosphatase are usually only moderately elevated except with the cholestatic variant

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7
Q

For patients with acute hepatitis, describe levels of ALT & AST

A

ALT>AST

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8
Q

For patients with alcoholic hepatitis, describe levels of ALT & AST

A

AST> ALT

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9
Q

Hypoalbuminemia is usually not present except in

A

protracted cases with severe malnutrition (or chronic hepatitis)

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10
Q

The best indicator of synthetic function of the liver with hepatitis is

A

PT

prolongation> 3 to 4 seconds following administration of Vitamin K is indicative of severe liver dysfunction

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11
Q

Preoperative evaluation of the emergent patient with acute hepatitis should include:

A

determination of the cause & degree of hepatic impairment
record drug exposures
presence of N/V–> may necessitate cricoid pressure
correction of dehydration & electrolyte abnormalities
mental status changes suggest severe hepatic impairment
premedication generally is not given to minimize drug exposure and confounds encephalopathy in patients with advanced liver disease

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12
Q

Recording of drug exposures for the acute hepatic patient should include

A

alcohol intake, recreational drug use, recent transfusions, & prior anesthetics

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13
Q

For alcoholics with acute hepatitis, the preoperative evaluation includse

A

inappropriate behavior or obtunded patient is a sign of acute toxicity
irritability, tremulousness, HTN, and tachycardia are signs of withdrawal

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14
Q

Vitamin K may be necessary to correct

A

a coagulopathy

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15
Q

The goal of intraoperative management of acute hepatitis is

A

to preserve existing hepatic function

avoid factors that may be detrimental to the liver

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16
Q

Intraoperative management of the patient with acute hepatitis includes

A

drug selection & doses should be individualized

acute viral hepatitis may produce increased CNS sensitivity to anesthetics

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17
Q

Intraoperative management of the alcoholic patient includes:

A

display cross-tolerance to IV and volatile anesthetic agents
requires CV monitoring due to the additive depressant effects of anesthetics & alcohol, possible presence of alcoholic cardiomyopathy

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18
Q

Patient classification of the patient with hepatitis is based on three distinct syndromes and is determined by

A

liver biopsy

chronic persistent hepatitis, chronic lobular hepatitis, & chronic active hepatitis

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19
Q

Chronic hepatitis is defined as

A

persistent hepatic inflammation for longer than 6 months as evidenced by elevated serum aminotransferases

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20
Q

In patients with acute hepatitis, intraoperative considerations include avoiding things known to reduce hepatic blood flow such as

A

hypotension, excessive SNS stimulation, high mean airway pressures during controlled ventilation

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21
Q

Intraoperative considerations for the patient with acute hepatitis include using “standard” induction doses of IV agents since their action is

A

terminated by redistribution versus metabolism or excretion

-prolonged duration of action may occur if large or repeated doses of IV agents are administered (particularly opioids)

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22
Q

The volatile agent of choice for the patient with acute hepatitis is

A

isoflurane as it has the least effect on hepatic blood flow

-inhalation agents are generally preferable to IV agents due to the dependence on liver metabolism and elimination

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23
Q

Additional considerations for the intraoperative management of the acute hepatitis patient includes

A

fewest number of anesthetic agents should be used

regional anesthesia can be used in the absence of coagulopathy

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24
Q

Describe chronic persistent hepatitis.

A

present with acute hepatitis (usually B or C) that has a protracted course but eventually resolves
characterized by chronic inflammation of the portal tracts with preservation of the normal cellular architecture (don’t have a lot of cell death with this)
usually does not progress to cirrhosis

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25
Describe chronic lobular hepatitis.
present with acute hepatitis that resolves but followed by recurrent exacerbations -characterized by FOCI of inflammation and cellular necrosis in the lobules usually does not progress to cirrhosis
26
Describe chronic active hepatitis.
occurs most commonly as a sequela of hepatitis B or C characterized by chronic hepatic inflammation with destruction of cellular architecture evidence of cirrhosis present initially or eventually develops
27
Patients with hep B or C infection usually have a favorable response to
antiviral medications Hep B: antiviral + immune modulator drugs (interferon) Hep C: antiviral can cure more than 95% of affected patients
28
Anesthetic management for the patient with chronic hepatitis includes:
patients with chronic persistent or chronic lobular hepatitis should be treated similar to those with acute hepatitis patients with chronic active hepatitis should be assumed to have cirrhosis and treated as such
29
For the patient with chronic hepatitis, laboratory test may show
only mild elevation of serum aminotransferases and generally these correlate poorly with severity of the disease
30
Cirrhosis is a progressive disease that eventually results in
hepatic failure
31
Most common causes of cirrhosis include:
alcohol abuse, NALFD, chronic active hepatitis (B & C), chronic biliary inflammation or obstruction
32
Regardless of the cause of cirrhosis, the result is
hepatocyte necrosis followed by fibrosis and nodular regeneration (scar tissue)
33
Destruction of the livers normal cellular and vascular architecture in the patient with cirrhosis produces:
obstruction of the portal venous flow leading to portal hypertension impairment of normal synthetic and metabolic functions leading to multisystem disease
34
3 major complications associated with cirrhosis include
variceal hemorrhage from portal hypertension intractable fluid retention in the form of ascites hepatic encephalopathy or coma
35
Approximately 10% of patients with cirrhosis have at least one episode of
bacterial peritonitis and some may eventually develop hepatocellular carcinoma
36
Manifestations of the patient with cirrhosis include
jaundice & ascites | other manifestations include: spider angiomas, palmar erythema, gynecomastia, spleenomegaly
37
Patients with cirrhosis are at increased risk for further deterioration of liver function due to
detrimental effects of anesthesia and surgery on hepatic blood flow already limited hepatic reserve
38
Successful anesthetic management depends on recognizing the multisystem dysfunction with cirrhosis
GI, circulatory, pulm, renal, hematological, infections, metabolic, & neurological the goal is to prevent or limit complications
39
Preoperative considerations for the patient with cirrhosis include
surgical risk is correlated with the degree of hepatic impairment severity of hepatic impairment and surgical risk can be estimated used the Childs-Turcotte-Pugh scoring system
40
The Childs=Turcotte-Pugh score measures:
total bilirubin, serum albumin, INR, ascites, & hepatic encephalopathy -assigning points based on levels and this helps determine survival
41
Gastrointestinal manifestations of the cirrhotic patient includes
portal hypertension leads to development of extensive venous collateral channels: gastroesophageal, hemorrhoidal, periumbilical, & retroperitoneal
42
The preoperative sign of portal hypertension is
abdominal wall veins
43
Massive bleeding from gastroesophageal varices is a major cause of morbidity & mortality and medical treatment includes
replace blood loss with IV fluids & blood products vasopressin, somatostatin, & propranolol to reduce the rate of blood loss balloon tamponade endoscopic sclerosis or ligation of the varices is about 90% effective bleeding continues or reoccurs then emergency surgery is indicated
44
Patients with cirrhosis may present with
anemia, thrombocytopenia/coagulopathy, leukopenia
45
For the patient with cirrhosis who has anemia, it is associated with
blood loss, increased RBC destruction, bone marrow suppression, & nutritional deficiencies
46
Thrombocytopenia/coagulopathy in the patient with cirrhosis is associated with
congestive spleenomegaly due to portal hypertension decreased hepatic synthesis of clotting factors enhanced fibrinolysis due to reduced elimination of factors that activate the fibrinolytic system
47
Leukopenia in the patient with cirrhosis is associated with
congestive spleenomegaly due to portal hypertension
48
Cirrhotic cardiomyopathy may be present due to
arteriovenous shunts & decreased blood viscosity | contribute to increased CO: above normal filling pressures, below normal SVR
49
Superimposed alcoholic cardiomyopathy may readily lead to
CHF
50
Circulatory manifestations of cirrhosis include
cirrhosis is typically associated with a hyperdynamic circulatory state CO is often increased and generalized peripheral vasodilation is present AV shunts can develop in the systemic and pulmonary circulation
51
Preoperative blood transfusion consideration sinclude:
protein breakdown from excessive blood transfusion can precipitate encephalopathy coagulopathy should still be corrected before surgery clotting factors should be replaced with blood products such as FFP & cryo platelet transfusion should be considered immediately prior to surgery for platelet count < 100,000
52
Describe the respiratory manifestations for a patient with cirrhosis.
hyperventilation is common resulting in resp alkalosis hypoxemia is frequent due to right to left shunts decrease lung volumes (particularly FRC) due to ascites fluid elevation of the diaphragm--> results in atelectasis
53
Describe why hypoxemia occurs in patients with cirrhosis.
shunting is due to increased anomalous AV communication also have V/Q mismatch up to 40% of CO involved
54
Describe preop labs/procedures that should be performed related to the respiratory manifestations of the patient with cirrhosis.
chest film & ABG to diagnose hypoxemia & atelectasis as they may not be evident from clinical examination paracentesis should be considered for massive ascites with pulmonary compromise
55
Alterations in fluid & electrolyte balance are manifested as
ascites, edema, electrolyte abnormalities, & hepatorenal syndrome
56
The following methods are believed to be responsible for ascites:
portal hypertension hypoalbuminemia seepage of protein-rich lymph fluid from the surface of the liver avid renal sodium (& often water) retention
57
Describe how portal hypertension leads to ascites.
increased hydrostatic pressure favors fluid transudation across the intestine into the peritoneum
58
Describe how hypoalbuminemia leads to ascites.
decreases plasma osmotic pressure favors fluid transudation
59
Describe how seepage of protein-rich lymph fluid from the surface of the liver leads to ascites.
secondary to distortion and obstruction of lymphatic channels
60
Describe how avid renal sodium (and often water) retention lead to ascites.
hepatorenal syndrome
61
In relation to renal manifestations & fluid balance, patients with cirrhosis and ascites have
decreased renal perfusion altered intrarenal hemodynamics enhanced proximal and distal tubule Na+ reabsorption impairment of free water clearance
62
Describe the electrolyte abnormalities of the patient with cirrhosis and ascites.
hyponatremia is common- dilutional | hypokalemia is common- excessive K+ loss secondary to hyperaldosteronism or diuretics
63
The renal manifestations and fluid balance abnormalities in cirrhosis are most severe with the onset of
hepatorenal syndrome
64
Hepatorenal syndrome is afunctional deficit in patients with cirrhosis that usually follows:
gastrointestinal bleeding aggressive diuresis sepsis major surgery
65
Hepatorenal syndrome is characterized by
progressive oliguria, avid Na+ retention, azotemia, intractable ascites, & very high mortality rate
66
Treatment for hepatorenal syndrome is
supportive in nature and often unsuccessful unless a liver transplant is performed
67
The anesthetic management of the cirrhotic patient with renal manifestations and fluid balance includes:
judicious use of periop fluid management use colloid infusion for fluid correction avoid overzealous preop diuresis importance of preserving renal function periop is critical diuresis of ascites and edema should be accomplished over several days
68
Loop diuretics should only be used after
bed rest, Na restriction, and spironolactone therapy have failed
69
Hepatic encephalopathy is characterized by
alterations in mental status fluctuating neurological signs- asterixis, hyperreflexia EEG changes some patients also have increased ICP
70
Metabolic encephalopathy may be related to the amount of
hepatocellular damage and degree of shunting of portal blood directly into the systemic circulation
71
Accumulation of toxins originating in the GI tract and normally metabolized in the liver that may cause hepatic encephalopathy include:
ammonia methionine metabolites short chain fatty acids phenols
72
Encephalopathy should be treated
preoperatively
73
It is recommended to avoid ____ in patients with encephalopathy
sedatives
74
Factors known to precipitate hepatic encephalopathy include
GI bleeding, increased dietary protein intake, hypokalemic alkalosis from vomiting or diuresis, infections, worsening liver function
75
The drug response to agents is unpredictable due to changes in
CNS sensitivity, volume of distribution, protein binding, drug metabolism & drug elimination
76
The most important thing we can do with our drugs for liver patients include
titration!
77
Volume of distribution of highly ionized NMBAs is increased & therefore
it requires greater than normal loading doses
78
hepatic elimination of NMBAs is decreased and therefore requires
lower than normal maintenance doses
79
The cirrhotic liver is very dependent on
hepatic arterial blood flow due to reduced portal blood flow
80
Preservation of hepatic arterial blood flow is critical in the cirrhotic patient and we can do this by
avoiding anesthetic agents that potentially reduce hepatic arterial blood flow
81
Regional anesthesia can be used in cirrhotic patients without
thrombocytopenia or coagulopathy but must take great care to avoid hypotension
82
The most highly recommended anesthesia for the cirrhotic patient is
propofol induction with isoflurane maintenance in oxygen or air-oxygen with Cisatricurium as the NMBD
83
Cardiovascularly unstable patients and those with active bleeding should have
awake intubation or RSI with cricoid pressure using ketamine or etomidate and succinylcholine
84
RSI with cricoid pressure may be indicated for the liver patient because
preoperative nausea, vomiting, GI bleeding, and abdominal distension
85
Opioid supplementation for the cirrhotic patient will
reduce the volatile agent requirement but have prolonged half life leading to prolonged respiratory depression
86
Monitoring of the cirrhotic patient includes:
monitor 5 lead EKG to detect ischemia (particularly in patients receiving vasopressin as they may have cirrhotic and alcoholic cardiomyopathy) - supplement pulse ox with ABGs to evaluate acid base status - patients with large R to L shunts may not tolerate N2O & may require PEEP - catheter to monitor UO- consider mannitol for persistent low urine output
87
Most patients with cirrhosis should have intrarterial monitoring due to rapid changes in BP as a result of
excessive bleeding, rapid intercompartmental fluid shifts & surgical manipulations
88
Intravascular volume is difficult to assess in cirrhotic patients and therefore they may need
CVP or PAP monitoring
89
When evacuating ascites fluid, consider that removal of large amounts of ascites fluid may require
IV colloid solutions to prevent profound hypotension
90
Fluid shifts can occur in patients who have
prolonged surgical procedures & evacuation of ascites fluid
91
Intraabdominal procedures in the patient with cirrhosis are often associated with
excessive bleeding due to venous engorgement from portal hypertension, adhesions from previous surgery, coagulopathy
92
For fluid replacement in the cirrhotic patient, most patients are on Na+ restriction preoperatively. Intraoperatively preservation of intravascular fluid volume and urinary output
takes precedence | use of predominantly colloid solutions may be preferable to avoid Na+ overload and to increase plasma osmotic pressure
93
Most patients are anemic & have a coagulopathy and therefore require
RBC transfusion preoperatively
94
Significant transfusions can result in citrate toxicity because
citrate is normally metabolized by the liver cirrhosis impairs citrate metabolism citrate binds to serum Ca++ and leads to hypocalcemia IV Ca++ is often necessary to reverse the negative inotropic effects of decreased ionized Ca
95
Treatment of extrahepatic obstruction is usually
surgical
96
Treatment of intrahepatic cholestasis is
medical
97
Both extrahepatic & intrahepatic obstruction produce a
predominantly conjugated hyperbilirubinemia and marked elevation in alk phos
98
Patients with symptomatic gallstone disease (cholelithiasis) usually present with
biliary colic secondary to obstruction of the cystic duct
99
Cholangitis is suggestive due to
concomitant chills or high fever suggesting an ascending bacterial infection of the biliary system
100
Gallstones can obstruct the
pancreatic duct and cause acute pancreatitis
101
The most common cause of cholestasis is
extrahepatic obstruction of the biliary tract (obstructive jaundice)
102
Extrahepatic obstruction can be due to
gallstones, stricture, & tumor in the common hepatic duct
103
Cholestasis can also be caused by
intrahepatic obstruction
104
Intrahepatic obstruction can be due to
suppression or stoppage of bile flow at the level of the hepatocyte or bile canaliculus most commonly results from viral hepatitis or idiosyncratic drug reaction
105
Hepatobiliary disease is characterized by
cholestasis- suppression of stoppage of bile flow
106
Patients with hepatobiliary disease most commonly present to the OR for
cholecystectomy
107
Patients with acute cholecystitis should be treated
medically before coming to the OR
108
Treatment for acute cholecystitis includes
nasogastric suction, IV fluids, antibiotics, and opioid analgesics
109
Patients suffering from serious complications related to hepatobiliary disease may require
emergency cholecystectomy as it is resulting in destruction of hepatocytes
110
Patients with extrahepatic biliary obstruction from an cause readily develop
vitamin K deficiency - should be given vitamin K (requires 24 hours for a full response) - failure of the PT to correct prior to surgery may necessitate FFP
111
High bilirubin levels for the patient with hepatobiliary disease may be associated with
renal failure
112
Long standing extrahepatic biliary obstruction is associated with secondary
biliary cirrhosis & portal hypertension
113
Laparoscopy cholecystectomy will accelerate
recovery
114
Describe the use of opioids when an intraoperative cholangiogram is to be performed.
can be problematic opioid induced spasm of the sphincter of Oddi may theoretically result in a false-positive cholangiogram -some clinicians withhold opioids until after the cholangiogram has been performed sphincter of Oddi spasm can be treated with naloxone or glucagon
115
In patients with a biliary tract obstruction expect a prolonged
duration of action of drugs that are dependent on biliary excretion agents dependent on renal excretion are preferable
116
Common hepatic surgeries include
repair of lacerations, drainage of abscesses, & resection of tumors
117
How much of the liver can be resected?
80 to 85%
118
Cirrhosis greatly complicates anesthetic management and increases periop mortality, preparation includes
multiple large bore IVs, fluid & blood warmers, rapid infusion devices, direct arterial & CVP monitoring advisable, & avoidance of hypotension
119
Postoperative complications of hepatic surgery include
bleeding, sepsis, & hepatic dysfunction
120
Postoperative __________ may be necessary in patient undergoing extensive resection
mechanical ventilation
121
______ may occur following large liver resections
hypoglycemia
122
Drainage of an abscess may be complicated by
peritoneal contamination
123
Administration of ____ may reduce blood loss.
antifibrinolytics; aprotinin, aminocaproic acid, tranexamic acid

Pathophys II (43 decks)

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