Hepatic pearls

Question 1

acute hepatitis is the result of

Answer 1

viral infection, drug reaction, & exposure to hepatotoxin

Question 2

Hep C produces

Answer 2

asymptomatic carriers

no effective vaccine is currently available

Question 3

Infectious carriers pose a major health threat to OR personnel:

Answer 3

avoid direct contact with blood & secretions
immunization is highly effective against hep B infection
No vaccine for hep C is available and prior infection does not confer immunity upon re-exposure
post-exposure prophylaxis with hyperimmune globulin is effective for Hep B not C

Question 4

Most common cause of drug-induced hepatitis is

Answer 4

Alcohol induced

Question 5

Patients with hepatitis are at risk for further hepatic dysfunction & hepatic failure:

Answer 5

encephalopathy
coagulopathy
Hepatorenal syndrome

Question 6

Acute hepatitis preop labs that should be addressed include:

Answer 6

Bilirubin, albumin, prothrombin time

Question 7

In acute hepatitis, (describe what happens with transaminases)

Answer 7

elevated transaminases do not correlate well with the degree of cellular necrosis

Question 8

Prolongation with INR >1.5 following administration of Vitamin K is indicative of

Answer 8

severe liver dysfunction

Question 9

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

Answer 9

• determination of the cause & degree of hepatic impairment
• record drug exposures including- alcohol intake, rec drug use, recent transfusions, & prior anesthetics
• presence of N/V
• correct dehydration & electrolyte abnormalities
• mental status changes suggest severe hepatic impairment
• alcoholics- signs of withdrawal vs. signs of acute toxicity
• premeds like benzos are generally not given to minimize drug exposure & confounds encephalopathy

Question 10

Goal of intraoperative management for the acute hepatitis patient is

Answer 10

preserve existing hepatic function

avoid factors that may be detrimental to the liver

Question 11

The volatile agent of choice due to the least effect on hepatic blood flow is

Answer 11

isoflurane

Question 12

“Standard” induction doses of IV agents can generally be used as

Answer 12

their action is terminated by redistribution versus metabolism or excretion

Question 13

If large or repeated doses of IV agents are administered to the patient with hepatitis,

Answer 13

prolonged duration of action may occur (particularly w/ opiods)

Question 14

Avoid the following things that are known to reduce hepatic blood flow:

Answer 14

sympathetic stimulation, hypotension, high mean airway pressures

Question 15

Chronic hepatitis is defined as

Answer 15

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

Question 16

Patient classification of chronic hepatitis is determined by

Answer 16

liver biopsy

syndromes include- chronic persistent hepatitis, chronic lobular hepatitis, & chronic active hepatitis

Question 17

Chronic persisitent hepatitis

Answer 17

eventually resolves
usually does not progress to cirrhosis
characterized by chronic inflammation of the portal tracts with preservation of the NORMAL cellular architecture

Question 18

Chronic lobular hepatitis is

Answer 18

resolves but followed by recurrent exacerbations
characterized by foci of inflammation & cellular necrosis in the lobules
usually does not progress to cirrhosis

Question 19

Chronic active hepatitis

Answer 19

chronic hepatic inflammation with destruction of cellular architecture
evidence of cirrhosis present initially or eventually develops

Question 20

Describe the anesthetic management for patients with chronic persistent, chronic lobular, and chronic active hepatitis

Answer 20

chronic persistent & chronic lobular should be treated similar to those with acute hepatitis
chronic active hepatitis should be assumed to have cirrhosis and treated as such

Question 21

Most common causes of cirrhosis include:

Answer 21

alcohol abuse
NALFD
chronic active hepatitis (B & C)
chronic biliary inflammation or obstruction

Question 22

Regardless of the cause of cirrhosis, the result is

Answer 22

hepatocyte necrosis followed by fibrosis & nodular regeneration

Question 23

Vitamin K requires

Answer 23

24 hours for a full response

Question 24

These complications eventually develop in most patients with cirrhosis:

Answer 24

jaundice & ascites

Question 25

3 major complications associated with cirrhosis include:

Answer 25

variceal hemorrhage from portal hypertension intractable fluid retention in the form of ascites hepatic encephalopathy or coma

Question 26

Preoperative considerations for the patient with cirrhosis include

Answer 26

prevent or limit complications | can affect all organ systems: GI, circulatory, pulm, renal, hematological, infectious, metabolic, & neurological

Question 27

The severity of hepatic impairment & surgical risk can be

Answer 27

estimated using the Childs-Turcotte- Pugh scoring system | -has 2 clinical features & 3 lab assesssments

Question 28

List what is included in the Childs- Turcotte Pugh score assessment:

Answer 28

total bilirubin, serum albumin, INR, ascites, & hepatic encephalopathy

Question 29

Gastrointestinal manifestations of cirrhosis include:

Answer 29

extensive venous collateral channels- gastroesophageal | hemorrhoidal, periumbilical, & retroperitoneal

Question 30

A major source of morbidity & mortality for the patient with cirrhosis is:

Answer 30

massive bleeding from gastroesophageal varices medical tx. includes balloon tamponade, replace blood loss, vasopressin, somatostatin, & propranolol to reduce rate of blood loss

Question 31

The hematological manifestations of the cirrhotic patient include

Answer 31

anemia, thrombocytopenia/coagulopathy, & leukopenia (usually due to things backing up in the spleen)

Question 32

In regards to preoperative blood transfusions, _____ can precipitate encepalopathy

Answer 32

protein breakdown from excessive blood transfusions

Question 33

Circulatory manifestations of cirrhosis include:

Answer 33

cardiac output is often increased & generalized peripheral vasodilation is present (similar to sepsis) - AV shunts can develop in the systemic & pulmonary circulation

Question 34

Cirrhotic cardiomyopathy may be present due

Answer 34

increased cardiac output as a result of above normal filling pressures and below normal SVR

Question 35

Mechanisms believed to be responsible for ascites include:

Answer 35

portal hypertension, hypoalbuminemia, seepage of protein-rich lymph fluid from the surface of the liver, avid renal sodium (and often water) retention

Question 36

Respiratory manifestations of cirrhosis include

Answer 36

hyperventilation is common and results in primary respiratory alkalosis

Question 37

Hypoxemia is frequent due to

Answer 37

right to left shunts - shunting is due to increase anomalous AV - Also have V/Q mismatch - up to 40% of CO is involved

Question 38

Ascites fluid (resp. issues)

Answer 38

causes an elevation of the diaphragm leading to decreased lung volumes (particularly FRC) resulting in atelectasis

Question 39

Renal manifestations & fluid balance abnormalities are most severe with

Answer 39

the onset of hepatorenal syndrome

Question 40

Hepatorenal syndrome is characterized by:

Answer 40

progressive oliguria, avid Na+ retention, azotemia, intractable ascites, & very high mortality rate

Question 41

Hepatorenal syndrome usually follows

Answer 41

GI bleeding, aggressive diuresis, sepsis, & major surgery

Question 42

Acute intravascular fluid deficits should be corrected with

Answer 42

colloid infusion

Question 43

Hepatic encephalopathy is characterized by

Answer 43

alterations in mental status, fluctuating neurological signs (asterixis, hyperreflexia), EEG changes, & increased ICP

Question 44

________ has been implicated in the development of hepatic encepalopathy

Answer 44

accumulation of toxins originating in the GI tract & normally metabolized in the liver (ammonia, phenols)

Question 45

Response to drugs is unpredictable due to changes in

Answer 45

CNS sensitivity, volume of distribution, protein binding, drug metabolism, & drug elimination

Question 46

Volume of distribution of highly ionized NMBAs is increased therefore:

Answer 46

requires greater than normal loading dose

Question 47

Hepatic elimination of NMBAs is decreased therefore

Answer 47

requires lower than normal maintenance dose

Question 48

The best thing you can do with your drugs is

Answer 48

titrate them

Question 49

The cirrhotic liver is very dependent on

Answer 49

hepatic ARTERIAL blood flow due to reduced portal blood flow

Question 50

Induction with ____ is recommended

Answer 50

propofol | cisatricurium is the NMBA of choice

Question 51

Removal of large amounts of ascites fluid may require

Answer 51

IV colloid solutions to prevent profound hypotension

Question 52

Significant transfusions can result in citrate toxicity. IV

Answer 52

Ca2+ is often necessary to reverse the negative inotropic effects of decreased ionized Ca

Question 53

The most common cause of cholestasis is

Answer 53

extrahepatic obstruction | due to gallstones, stricture, tumor in the common hepatic duct

Question 54

Cholestasis can also be caused by

Answer 54

intrahepatic obstruction due to suppression or stoppage of bile flow in the bile canalciulus results from viral hepatitis or idiosyncratic drug reaction

Question 55

Treatment of extrahepatic obstruction vs. intrahepatic

Answer 55

extrahepatic- surgical | intrahepatic- medical

Question 56

Both intrahepatic & extrahepatic produce a

Answer 56

predominantly conjugated hyperbilirubinemia & marked elevation in alk phos

Question 57

Hepatobiliary disease is characterized by

Answer 57

cholestasis- suppression or stoppage of bile flow