Hepatic PPT Flashcards
(116 cards)
1
Q
GETA for ERCP should include
A
RSI for possible aspiration risk
Standard emergence
2
Q
ERCP, endoscopic sphincterotomy, and biliary stenting are indicated for?
A
Removal of common duct stones aka choledocholithiasis
3
Q
Hepatitis B mode of transmission
A
Blood, Body fluids (semen, saliva)
Hepatitis D similar mode of transmission; coinfection with B
4
Q
How does acute intoxication affect MAC?
A
reduces MAC
5
Q
Increased risk of bleeding or clotting?
Increased: Factor VIII, vWF, fibrinogen
Decreased: Protein C, protein s, antithrombin III
A
Increased risk of clotting
6
Q
Mode of transmission for hepatits A?
A
Hepatitis with a vowel come from the bowel
A, E
Fecal-oral, sewage, contaminated shellfish
7
Q
Altered mental status and asterixis are features in?
A
Hepatic encephalopathy
8
Q
What drug class can induce sphincter of Oddi tone/spasm
A
Narcotics
9
Q
*Table Hypoxemia refractory to O2 therapy & PEEP can be due to what effect of cirrhosis?
A
Hepatopulomary syndrome
decreased FRC
10
Q
Anesthetic management of acute hepatitis
A
- Use iso, sevo, or des, avoid halothane
- Maintain normocapnia
- Avoid PEEP ( if needed no more than 5)
- Provide adequate/liberal IV hydration
- Consider regional if coagulation is acceptable and procedure allows
11
Q
If indicated, attempt to correct prothrombin time to within ___seconds of normal.
What is normal PT?
A
2 seconds
Normal PT 10.9-12.5 seconds
12
Q
What alternative to glucagon can you give for sphincter of oddi spasm
A
Narcan, nalbuphine
nitro, atropine, glycopyrolate
13
Q
What medications should be avoided in liver disease
A
Hepatotoxic drugs or CYP450 inhibitors
- Acetaminophen
- Halothane
- Amiodarone
- ABT: PCN, tetracycline, sulfonamides
14
Q
What factors should lead to consideration of GETA vs deep sedation for ERCP
A
High aspiration risk
Uncooperative
Complex ercp
15
Q
A
16
Q
How to decrease risk of PONV?
A
Treat preemptively
17
Q
*What are s/s of acute pancreatitis?
A
Sudden onset abd pain gradually becoming more severe
N/V/D
Anorexia
Elevation of pancreatic enzymes
18
Q
When should you consider using cryo?
A
If FFP ineffective in correcting PT
If a fibrinogen abnormality is present
19
Q
What is normal intra-abd CO2 insufflation pressure?
A
10-12mm Hg
20
Q
Lab findings for choledocholithiasis?
A
Increased bilirubin & alkaline phosphatase levels
21
Q
Cephalad displacement of the diaphragm during trend and subsequent intra abd co2 insufflation can lead to
A
Decreased: lung volumes, lung compliance, FRC, PaO2
Increased:PIP, PaCO2
Atelectasis
Possible change of position of ETT –>endobronchial intubation
22
Q
Hypercapnia and acidosis have vasoconstrictive or vasodilatory effects on hepatic blood flow? Does it cause an increase or decrease in BF?
A
Vasodilatory effect
Increases HBF
23
Q
Effects of intra-abd pressure > 15mm Hg
A
Decreased: venous return, CO
Increased: SVR
24
Q
Apex* What are manifestations of alcohol withdrawal syndrome? Tx?
A
Early: tremors hallucinations, nightmares
Late: Increased SNS activity (tachy, htn, dysrhythmias) N/V, insomnia, confusion, agitation
Tx: Alcohol, BB, Alpha2 agonists
25
Decreased synthesis/decreased synthetic capacity of the liver is suggested in which lab values
Decreased albumin \<3.5 g/dL
Prolonged PT time \>12.5 Seconds
26
Describe minor vs major injury d/t halothane
Minor injury: increased ALT postop day 1-10
Major injury: Halothane hepatitis
27
What intraoperative factors contribute to decreased HBF?
Hypotension
Hemorrhage
Vasoactive drugs
Pneumoperitoneum (laparoscopy)
28
\*Table What are some cardiovascular effects of liver cirrhosis
Fluid retention
Peripheral edema
Ascites
29
Slow, steadily rising CO2 despite measures to decrease may indicate
Subcutaneous emphysema
30
Most NMB agents are prolonged in patients with liver disease due to what three factors?
1. Reduced pseudocholinesterase activity (sux)
2. Decreased biliary excretion (roc)
3. Larger volume of distribution ( as Vd increases drug elimination half life also increases)
31
\*S/S of endobronchial intubation
Absent lung sounds in unventilated lobe
Increased PIP unrelated to insufflation pressure
Desaturation
32
Considerations with cholangiograms
Have lead available
Be aware of patients allergies
Prepare to tx hypersensitivity preemptively or acutely prn
33
\* Table Considerations for hepatorenal syndrome include
Maintenance of renal perfusion
Caution with drugs eliminated by kidney
Avoidance of nephrotoxic drugs
34
This complication of laparoscopic sx happens during trocar placement
Hemorrhage from inadvertent injury to blood vessels
35
Table\* Hysteroscopies, any previous abd sx, needle/trocar in vessel are all risk factors for?
CO2 embolism
36
\*WTH is biliary colic?
Pain that occurs when a gallstone is being passed and blocking a bile duct, typically intermittent
37
In the chronic alcohol abuser who is _not_ acutely intoxicated- is MAC increased or decreased?
MAC is increased
38
Hepatitis is likely to cause elevations in which lab tests ?
ALT (10-55units/L)
AST (10-40units/L)
ALT more specific for hepatic injuries
AST nonspecific, can originate from skeletal muscle, rbc, kidney, pancreas, brain and heart
39
What are some risk factors for liver disease?
Excessive alcohol intake IV drug use Use of hepatotoxic medications
40
\* Table _Chronic viral hepatitis lab findings_
AST/ALT
ALK
Bilirubin
INR
Albumin
AST and ALT levels: normal to 10x upper limit of normal
ALK: Normal to slightly elevated
Bilirubin: Normal to elevated
INR: Normal to elevated
Albumin: Normal to decreased
41
25% of blood flow to the liver comes from where?
Hepatic artery
42
Manifestations of alcohol withdrawal syndrome appear _____ hours
24-96
43
Endocrine features of liver cirrhosis
1. Less glucose production-watch for hypoglycemia
2. Decreased metabolism of insulin
3. Hypogonadism
44
Which VA causes the greatest reduction in hepatic flow?
Intraop or postop?
Halothane
Hepatotoxic postop
45
What measures can be taken to preserve hepatic blood flow in cirrhotic patients?
1. Avoid halothane
2. Consider regional if procedure and coagulation allow
3. Maintain normocapnia
4. Avoid PEEP if possible
5. Provide generous volume maintenance
6. Avoid hepatotoxic medications [acetominophen, sulonamides, tetracycline, penicillin, amiodarone]
46
\* Table What are some integument changes in liver cirrhosis
Jaundice
Spider angioma
Palmar erythema
Purpura
Petechiae
Caput medusae
47
Anesthetic plan for lap chole
Standard induction and maintenance: GETA with paralysis
48
\*Table Name neuro changes r/t liver cirrhosis
1. Hepatic encephalopathy
2. Peripheral neuropathy
3. Asterixis
49
Positive pressure ventilation, increased airway pressures and PEEP have what effect on hepatic blood flow?
Reduction
50
\*How to treat sphincter of Oddi spasm?
NNAGG: nitroglycerin, naloxone, atropine, glucagon, glycopyrolate
51
Controlled ventilation during lap chole minimizes the effects of?
Pneumoperitoneum and hypercarbia
52
\*What is the NMB agent(s) of choice for hepatic or renal dysfunction?
Benzylisoquinilines: Cisatracurium or Atracurium
because it uses hydrolysis and hoffman elimination
53
How to decrease the possibility of hypercarbia from absorbed CO2?
Ensure adequate ventilation (controlled ventilation) "Never spontaneously breathing no LMA's"
54
\*Table What are some reproductive changes r/t liver cirrhosis?
Amenorrhea
Testicular atrophy
Gynecomastia
Impotence
55
\*Table Metabolic manifestations of liver cirrhosis include
1. Hypokalemia
2. Hyponatremia
3. Hypoalbuminemia
56
_\* Table Chronic alcoholic liver disease lab findings_
AST/ALT
ALK
Bilirubin
INR
Albumin
AST:ALT ratio 2:1,
AST/ALT normal to \<8x upper limit of normal
ALK: Normal to elevated
Bilirubin: Normal to elevated
INR: Normal to elevated
Albumin: Normal to decreased
57
Reflex dilation of splanchnic capacitance vessels can happen when? What effect does is have on HBF?
Traction on abd viscera during intra-abd surgery
Decreases HBF
58
Barash video Laparoscopy highlights
Aspirate/decompress the stomach before trocar placement to decrease r/o gastric perforation
Ensure effective co2 elimination via titration MV
Decreased CO, reflex bradyarrhythmia due to vagal stimulation
59
Laparoscopic cholecystectomies have what % of converting to open procedures?
5%
60
Pneumothorax can be attributed to what intraoperative process during lap chole?
Retroperitoneal dissection of insufflated CO2
61
\*Table Liver cirrhosis has this effect on sodium balance
Hyponatremia
62
\*Table Effects of advanced cirrhosis and portal htn?
1. Normal or low CO
2. Ascites
3. Decreased GFR, AKI
63
Keep CO2 insufflation pressure
\<12 mmHg
64
Table\* Hematologic effects of liver cirrhosis
1. Anemia
2. Thrombocytopenia
3. Leukopenia
4. Coagulopathy
5. Splenomegaly
65
75% of blood flow to the liver comes from?
Portal vein
66
\* Table _Nonalcoholic fatty liver disease lab findings_
AST/ALT
ALK
Bilirubin
INR
Albumin
AST:ALT ratio \<1
AST/ALT levels normal to \<5x upper limit of normal
ALK: Normal to 2-3 x upper limit of normal
Bilirubin: Normal to elevated
INR: Normal to elevated
Albumin: Normal to decreased
67
False-positives during a cholangiogram can be caused by
Sphincter of Oddi spasm
68
O2 delivery is what % by hepatic artery? portal vein?
50% 50%
69
\* Table _Acute viral hepatitis lab findings_
AST/ALT
ALK
Bilirubin
INR
Albumin
AST and ALT \>25 x upper limits of normal
ALK: Normal to elevated
Bilirubin: Normal to elevated
INR: Normal to elevated
Albumin: Normal to decreased
70
\*Table Very careful sterile technique is employed for these patients due to compromised immune system
Liver Cirrhosis
71
Upper limit of intra-abd CO2 insufflation pressure?
18mm Hg may be tolerated in obese patients
72
S/S of acute cholecystitis include?
Abd pain, RUQ tenderness, N/V, fever
73
What are the benefits of carbon dioxide during laparoscopic surgery?
1. Nonflammable
2. Absorbable
3. Diffusible
4. Inexpensive
5. Transparent
74
\*Table Increased risk of GI bleeding stems from what effects of liver cirrhosis?
Portal HTN and varices
75
What % of CO does the liver receive?
20%- 25% (=1500mL/min)
76
What are the complications of ERCP?
Acute pancreatitis, hemorrhage and perforation
77
Which grades of SubQ emphysema will most likely remain intubated?
Grades IV and V
78
Hypocapnia and alkalosis exert what effect on hepatic blood flow?
Vasoconstricting effects that result in decreased flow
79
\*Table What are the effects of cirrhosis and portal htn?
1. High CO
2. Ascites
3. Kidneys susceptible to ischemia but normal GFR
80
Table\* Tachy, hypotension, increased cvp, hypoxia, cyanosis, ETCO2 biphasic change, Rt heart strain on ecg, increased pulmonary artery pressures on tee are all features of
CO2 embolism
81
Other than pneumoperitoneum, what can cause increased airway pressures?
Insufficient paralysis
Bronchspasm
Kinked ETT
82
Mode of transmission hepatitis C
Percutaneously
Blood and body fluids (semen, saliva)
83
What action can be taken in case of cardiopulmonary compromise during laparoscopic sx
Deflate pneumoperitoneum
84
Alcohol _______ GABA receptor activity
_Increases/potentiates_
Enhanced effects of benzos, barbs, propofol, other CNS depressants
85
Hypothermia can be caused by
dry gas insufflation
86
Decreased venous return and increased lung volumes are seen in this position
Reverse trend
87
During lap chole when is the patient in trend position?
Trocar placement
88
\*Table Name GI manifestations r/t liver cirrhosis
Anorexia
Dyspepsia
N/V
Change in bowel habits
Dull abd pain
Fetor hepaticus (sweet, pungent smell of breath)
Esophageal/gastric/hemorrhoidal varices
Hematemesis
Congestive gastritis
89
\* Table _Shock liver lab findings_
AST/ALT
ALK
Bilirubin
INR
Albumin
AST: ALT ratio 1:1
AST and ALT \>50x upper limit of normal
ALK: Normal to elevated
Bilirubin: Normal to elevated
INR: Normal to elevated
Albumin: Normal to decreased
90
What are some physical findings of impaired liver function?
Hepatomegaly, splenomegaly, spider nevi, gynecomastia, jaundice, ascites, caput medusa
91
Table\* Hepatic encephalopathy increases or decreases anesthetic requirements? analgesic requirements?
Decreased anesthetic and analgesic requirements
\*intubation to protect airway
92
Why is the patient tilted to the left during trend positon?
To move away the stomach, duodenum and transverse colon away from the field
93
Bradyarrythmia due to insufflation is usually transient but if sustained and hypotensive tx with?
Anticholinergic -Atropine
94
Alcohol inhibits what receptors?
NMDA receptor
Acts like NMDA receptor antagonist
95
Which VA causes moderate dose-dependent decrease in hepatic blood flow?
Desflurane
96
\* Tx of CO2 embolism
Stop peritoneal insufflation and desufflate immediately, position patient head down and in left lateral decubitus, hyperventilate with 100% Fio2. If not effective, consider aspiration of embolus from a central line. For massive embolism, CPR/ACLS and ultimately CABG may be needed. In cases of possible cerebral embolism, hyperbaric o2 may be used.
97
Minimal dose-dependent decreases in hepatic blood flow with which VA's?
Iso & Sevo
98
Trend position effect on venous return
Increased venous return
99
\* Cardiovascular complications of abdominal laparoscopy
Decreased venous return
Decreased CO Increased SVR
Decreased blood flow to splanchnic and renal circulation
100
\* Table Portopulmonary htn and hyperdynamic circulation present in liver cirrhosis can lead to what complications?
Right ventricular failure
cardiogenic shock/ vasodilatory shock
101
102
Where does the liver derive its blood supply from?
Hepatic artery & portal vein
103
True/false prior abd sx does not increase risk of open procedure
False- prior abdominal sx does increase risk of open procedure (scarring, issues with visualization)
104
\*In the setting of abd insufflation which MV setting is best?
Pressure control mode prevents alveolar derecruitment, provides physiologic minute ventilation while minimizing the risk of barotrauma
105
Decreased PO2, increased PIP, hemodynamic instability and possibly subcuatneous emphysema are manifestations of
Pneumothorax
106
To increase duodenal motility during ERCP which drugs may you be asked to give?
Glucagon or Secretin
| (check BG if glucagon given)
107
Inherent risks of deep sedation
Loss of protective airway reflexes
Respiratory depression
108
Portal vein collects blood from where?
Blood that leaves the spleen, stomach, small and large intestine, gallbladder and pancreas.
109
Anesthetic plan for acutely intoxicated
Aspiration precautions/full stomach
(impaired pharyngeal reflexes d/t alcohol)
RSI
Decreased MAC
110
True/False OGT's are necessary for lap chole's
True- used to decompress the stomach
111
Lap Chole's may be contraindicated in what disease states?
Uncorrectable coagulopathy
Severe COPD
Severe cardiac disease (unable to tolerate increased intraabd pressure)
112
Hypercapnia & acidosis have what effect on liver blood flow?
Vasodilatory effects = increased blood flow
113
Hypocapnia and alkalosis have what effect on liver blood flow?
Vasoconstricting effects= decreased blood flow
114
Most common reason for low albumin?
chronic liver failure caused by cirrhosis
115
Hepatopulmonary syndrome is defined as the triad of?
1. Liver diease
2. Arteriolar deoxygenation
3. Widespread pulmonary vasodilation
116
