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Co-Existing Disease > Liver > Flashcards

Liver Flashcards

1
Q

Why do we want to be careful with our opioid use in liver disease?

A

Risk for sphincter of Oddi spasm

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2
Q

Sphincter of Oddi spasm will happen in about __% of the population given opioids

A

3%

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3
Q

Is there any way to predict who will experience sphincter of Oddi spasm?

A

No.

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4
Q

How can we antagonize sphincter od Oddi spasm?

A 
Glucagon (.3mg up to 3 times)
- can cause hyperglycemia and vomiting
NTG (10mcg/min)
- good for those with heart failure
Naloxone (Narcan)
- Will reverse the analgesic effect and have a bunch of other SE
Nubain
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5
Q

What is the incidence for halothan hepatitis?

A

1: 10,000-30,000

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6
Q

This IA doesn’t cause hepatitis and why?

A

Sevoflurane does not undergo metabolism to trifluoroacetylated metabolites and is therefore not expected to produce immune-mediated hepatotoxicity or to cause cross-sensitivity

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7
Q

Reasons for post-op hepatic dysfunction

A

o Multi-factorial
o Review all drugs administered
o Check for sepsis
o Evaluate the possibility of increased bilirubin
o Rule out occult hematomas → hyperbilirubinemia
o Review peri-operative record for hypotension, hypoventilation, hypoxemia, hypercarbia, and hypovolemia***

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8
Q

This is the most common blood borne pathogen in the US

A

Hep C

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9
Q

HEV is transmitted via this route and in locations

A

Transmitted enterically

Asia, Africa, and Central America

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10
Q

In viral hepatitis, AST/ALT values may be as high as

A

400-4,000

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11
Q

Treatment for Hepatitis B

A

Interferon, Lamivudine, Adefovir (these will affect what drugs we use

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12
Q

Treatment for Hepatitis C

A

Interferon and Ribavirin

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13
Q

Treatment for autoimmune hepatitis

A

Corticosteroids and AZT

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14
Q

Cirrhosis is most commonly due to

A

HepC and ETOH abuse

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15
Q

The hepatic artery and portal vein both supply 50% of O2 each, but ____ provides 75% of total blood flow and ____ provides 25% of total blood flow

A

Hepatic artery = 25%

Portal vein = 75%

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16
Q

The liver is the site of synthesis of all clotting factors except

A

vWF

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17
Q

Patients with cirrhosis will have hyperdynamic circulation. What does this mean?

A

High CO

Low SVR

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18
Q

S/S of cirrhosis

A 
o	Fatigue /malaise 
o	Anorexia/ weakness
o	Nausea/ vomiting
o	Abdominal pain 
o	Jaundice /spider nevi 
o	Hypoalbuminemia
o	Coagulation disorders
o	Endocrine disorders
o	Hepatic encephalopathy
o	Gastroesophageal variceal
o	Hepatomegaly /ascites
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19
Q

Many alcoholics can get cardiomyopathy. How does this affect your anesthetic?

A

Don’t give anything that depressed the myocardium

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20
Q

How do the majority of cirrhosis patients die during abdominal surgery?

A

60% die from bleeding

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21
Q

In cirrhosis, these clotting factors are deficient, and it results in these decreased lab values

A

Factors 2, 5, 7, 9, 10
Vitamin K
Low platelet count
Prolonged PT and INR

22
Q

These bleeding values are contraindications to elective surgery

A

Plts < 50,000

PT prolonged > 3 sec

23
Q

Treatment for cirrhosis induced coagulopathy

A

FFP
- Give 10-20mL/kg
- Contains all clotting factors, but will only last for 12-24 hours
Vitamin K (if malnutrition is present)
Platelets (give prophylactically for those <100,000)

24
Q

We must avoid this monitoring in cirrhosis patients!

A

Esophageal temp probe!

25
Q

Monitoring we want for cirrhosis patients!

A

Invasive monitoring (CVP, a-line)
PA Cath if severe cardiomyopathy
Always be checking blood glucose
Foley catheter for UO

26
Q

Why are cirrhosis patients considered full stomachs?

A

Alcohol use weakens the lower esophageal sphincter

27
Q

Liver patients tend to be (hyper/hypo)glycemic

A

Hypoglycemic. Give fluids with glucose

Pts are hypoglycemic d/t decreased hepatic gluconeogenesis.

28
Q

How should we maintain anesthesia for the patient with cirrhosis?

A

IA at 1/2 MAC with N2O and opioids

29
Q

In cirrhosis, we need a (higher/lower) dose of NMRs and why?

A

Need higher dose because Vd will be increased

30
Q

What NMBs are best for cirrhosis

A

Mivacurium, atracurium, cisatracurium*
(the ones metabolized in blood)
Sux is apparently ok too

31
Q

Reasons why liver patients are at risk for morbidities post-op

A 
Pneumonia
Bleeding
Sepsis
Poor wound healing
Liver dysfunction
DT’s
32
Q

Within __-__ hours from alcohol withdrawal, the patient may become tremulous

A

6-8

33
Q

Alcohol hallucinations and grand mal seizures occur within __ hours after a patient’s last drink

A

24

34
Q

DTs usually appear within __ hours of withdrawal and are preceded by _______

A

72

tremulousness, hallucinations or seizures

35
Q

What is the treatment for DTs?

A

Benzos

Give these up front

36
Q

Other comorbidities that alcoholics may have

A

Hypothermia, alcoholic poluneuropathy , Wernicke-Korsakoff syndrome, Pernicious anemia

37
Q

Overall considerations for the maintenance phase of anesthesia

A

No IAs with bad effects on the liver (no decrease in hepatic BF or risk of hepatitis).
- Stick to sevo*, iso, and des
Maintain BP to ensure adequate hepatic BF
Use NMBs that are metabolized in the blood (miv, atra, cisatra, sux)
Maintain with IA at 1/2 MAC with N2O and opioids
Don’t give anything that will depress the heart!
Patients will have low protein binding
Bleeding risk
Considered full stomachs (poor lower esophageal sphincter tone)
Give fluids that contain glucose

38
Q

Why the fuck is porphyria listen again in the liver ppt?

A

Because people with liver problems can develop porphyria even without a genetic predisposition (probably lack of enzyme formation by the liver)

39
Q

This enzyme is deficient in porphyria

A

ALA synthetase

40
Q

A purple/blue case of _____ is associate with porphyria

A

urine and feces

41
Q

Triggers for porphyria crisis

A

Enzyme inducing drugs, other drugs (BAD SENK), hormonal fluctuations (menstruation, fasting, dehydration, stress, infection)

42
Q

S/S of porphyria attack

A

abd pain, N/V, ANS instability (HTN and tachycardia), electorlyte (Na, K, MG) disturbances, neuro psych manifestations, weakness.
Weakness can progress to quadriparesis and respiratory failure.

43
Q

Treatment for porphyria

A 
Hematin 3-4mg/kg (drug of choice)
Remove triggering agents
Hydration
Carbohydrates (b/c a trigger is fasting)
Treat pain and N/V
Beta blockers for HTN & tachycardia
Benzodiazepines for seizures
Fluid and electrolyte balance
44
Q

When is regional anesthesia not a good choice in porphyria?

A

During an acute exacerbation

45
Q

Should a patient going for a cholecystectomy be intubated with a RSI?

A

Yes, because the patient may have ileus or have been vomiting and will be high aspiration risk

46
Q

Why do patients have hyperdynamic circulation with liver disease?

A

Accumulation of vasodilating compounds like prostaglandins and interleukins.
Reduced blood viscosity may also play a role.

47
Q

Any IAs that decrease hepatic BF will increase serum concentrations of

A

Alpha-GST

48
Q

Blood volume in liver disease

A

Decreased in central circulation, but increased in splanchnic circulation, pulmonary, muscle, and cutaneous as well.

49
Q

GA Considerations in porphyria

A
  • Use short acting agents
  • Monitor for instability
  • Induction
  • Propofol, ketamine → these are ok to use in porphyria
  • Maintenance
  • Nitrous, inhaled anesthetics, opioids, NDMR
  • CP bypass a stress
50
Q

RA considerations in porphyria

A
  • No contraindication
  • Pre anesthetic neuro evaluation (any numbness or tingling?)
  • CV instability d/t sympathectomy, ANS neuropathy, hypovolemia
  • Not best choice during acute exacerbation**
51
Q

Is cimetidine good or bad in porphyria?

A

GOOD. It decreases heme consumption and decreases ALA synthetase activity.

52
Q

These meds can be given to treat porphyria

A

Hematin 3-4 mg/kg IV, somatostatin, plasmapheresis

Co-Existing Disease (10 decks)

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