Liver 5

Question 1

The anhepatic phase begins with

Answer 1

removal of the native liver

Question 2

The anhepatic phase ends with

Answer 2

implantation of the donor liver

Question 3

Surgical objectives of the anhepatic phase inlcude

Answer 3

removal of sick liver
implantation of donor liver

Question 4

Neohepatic phase begins with

Answer 4

reperfusion of donor liver

Question 5

The neohepatic phase ends with

Answer 5

biliary anastomosis (or transport to the ICU)

Question 6

Surgical objectives of the neohepatic phase include

Answer 6

reperfusion of donor liver
anastomosis of hepatic artery
anastomosis of biliary structures

Question 7

During the pre-anehpatic phase, patients are at risk of

Answer 7

gastric regurgitation and pulmonary aspiration d/t liver disease and ascites

Question 8

The pre-anhepatic phase dictates a

Answer 8

rapid sequence induction

Question 9

Items needed in the pre-anhepatic phase include

Answer 9

rapid infuser to administer warm fluids and replace blood products as needed b/c significant blood loss is a risk

Question 10

Goals of the pre-anhepatic phase include

Answer 10

hgb >7 g/dL
platelets >40,000
fibrinogen >100 mg/dL
and MA (TEG) >45

Question 11

With the pre-anhepatic phase, anticipate

Answer 11

CV instability (hypotension) as a result of drainage of ascites, compression of vascular structures, and ongoing blood loss

Question 12

A lower CVP will reduce

Answer 12

blood loss during surgical dissection

Question 13

Just before clamping the IVC, increase the CVP to

Answer 13

10 cmH2O

Question 14

What are the approaches the surgeon can use for hepatic isolation?

Answer 14

bicaval clamp
piggyback technique
venovenous bypass

Question 15

The bicaval clamp is when

Answer 15

clamps are applied to the IVC (above and below the liver) for full obstruction of IVC flow

Question 16

Special considerations of the bicaval clamps include

Answer 16

significant preload reduction (hypotension, tachyardia)
aggressive fluid administration to combat hypotension can lead to volume overload when the clamps are released

Question 17

The piggyback technique is when there is

Answer 17

side clamping of the IVC (partial obstruction to IVC flow)

Question 18

Special considerations of the piggyback technique include

Answer 18

less preload reduction as compared to bicaval clamping
reduced operating and warm ischemic times
fewer blood products required

Question 19

What is the venovenous bypass?

Answer 19

sites of cannulation include femoral vein & portal vein (outflow sites towards pump)
site of cannulation: axillary vein (return to body)

Question 20

Special considerations of venovenous bypass include

Answer 20

piggyback technique has reduced the need for VVB
VVB is a reasonable choice if the patient does not tolerate piggyback
associated with less hemodynamic instability, less blood loss, and prevention of portal and splanchnic congestion but it has a higher complication rate

Question 21

During the anhepatic phase, the patient will have no

Answer 21

liver function

Question 22

Common problems during the anhepatic phase include

Answer 22

worsening coagulopathy, ongoing blood loss, lactic acidosis, and hypoglycemia

Question 23

__________________ is used to combat acidosis during the anhepatic phase

Answer 23

Sodium bicarbonate (or another buffer)

Question 24

How often should labs be monitored during the anhepatic phase?

Answer 24

q15-30

Question 25

In preparation for reperfusion, pay close attention to

Answer 25

serum potassium as it will get higher when the donor liver is reperfused

Question 26

Warm ischemic times begins when the donor liver is

Answer 26

removed from the ice and extends until the donor liver is reperfused

Question 27

Warm ischemic time should not exceed

Answer 27

30-60 minutes

Question 28

Key complications of the neohepatic phase include

Answer 28

hyperkalemia hypocalcemia cytokine release lactic acidosis embolic debris hypovolemia systemic hypotension pulmonary hypertension hypothermia cardiac arrest

Question 29

The risk of hyperkalemia is highest during

Answer 29

the neohepatic phase

Question 30

First-line pharmacologic treatment for hyperkalemia includes

Answer 30

calcium chloride and sodium bicarbonate

Question 31

Avoid _________ as this will cause congestion in the graft

Answer 31

increased CVP

Question 32

Findings that suggest good graft function include

Answer 32

stabilization of serum glucose and acid-base status as well as prompt return to normothermia

Question 33

Post-reperfusion syndrome is defined as

Answer 33

systemic hypotension more than 30% below baseline for at least 1 minute during the first 5 minutes of reperfusion of the donor liver

Question 34

Signs of a poorly functioning graft include

Answer 34

continued hemodynamic instability and lack of bile output

Question 35

Pain control for liver transplants typically includes _____ and not __________

Answer 35

opioids (often PCA) and not epidural analgesia b/c of coagulation status

Question 36

Post-op considerations for liver transplant include

Answer 36

steroid-induced hyperglycemia antirejection medications impact immune function

Question 37

All of the following drugs improve biliary hypertension EXCEPT: a. naloxone b. nitroglycerine c. glucagon d. octreotide

Answer 37

d. octreotide

Question 38

The most common gallbladder diseases are caused by

Answer 38

obstruction or inflammation

Question 39

_____________increases the risk of PONB

Answer 39

glucagon

Question 40

_________ can precipitate spasm of the sphincter of oddi

Answer 40

opioids- problem if it causes a false-positive during a cholangiogram

Question 41

You can relax the sphincter of oddi with

Answer 41

glucagon, naloxone, or nitroglycerin glycopyrrolate and atropine may help as well

Question 42

___________ can cause an obstructive defect that impedes the flow of bile as well as pancreatic enzymes

Answer 42

Biliary stones

Question 43

If bile and pancreatic enzymes can't move into the small intestine, then they

Answer 43

back up into the liver and the pancreas

Question 44

Obstruction of the cystic duct leads to

Answer 44

gallbladder distension edema risk of perforation & jaundice

Question 45

Obstruction of the common bile duct leads to

Answer 45

cholecystitis jaundice pancreatitis peritonitis

Question 46

The incidence of gallstones increases with

Answer 46

obesity, aging, rapid weight loss, pregnancy, and women>men

Question 47

S/sx of biliary stones include

Answer 47

leukocytosis, fever, and RUQ pain pain is worse with inspiration (Murphy's sign)

Question 48

Prolonged NPO status increases the

Answer 48

likelihood of gallstone formation

Question 49

Biliary pathology includes

Answer 49

increased alkaline phosphatase, increased conjugated bilirubin, increased amylase, increased Y glutamyl transpeptidase, and increased 5'-nucleotidase

Question 50

Treatment of cholecystitis and cholelithiasis is

Answer 50

cholecystectomy

Question 51

treatment of choledocholithiasis is

Answer 51

ERCP

Question 52

Choledocholithiasis is

Answer 52

stones in the common bile duct

Question 53

___________ should be avoided due to bowel distension

Answer 53

Avoid N2O

Question 54

If there is liver dysfunction, ____________ should be selected

Answer 54

a benzylisoquinolinium NMB (cisatracurium or atracurium)

Question 55

Using naloxone in a surgical patient is

Answer 55

a poor choice