Liver reduced I Flashcards

Question

Pre-op Assessment - hepatitis

Answer 1

1. How long has the hepatitis been present 2. What stage is it 3. What type/mode of transmission 4. Signs/symptoms the pt is experiencing Is patient optimized for anesthesia (fluids, e-lytes) 5. Does everyone have proper vaccines in place?

Answer 2

Coags? Encephalopathy?

Answer 3

* NPO? * Volume status (often hypovolemic) * Other organ system involvement

Answer 4

Etiology: 1. Inflammation of the liver parenchyma 2. Viral 3. Autoimmune 4. Drug-Induced Types: * Acute * usually self-limiting and most often viral but can be caused by drugs/toxins * Chronic * Hepatic inflammation \>6 months * Cirrhosis, hepatocellular carcinoma or liver failure (ETOH/HCV/HBV/Autoimmune) S/S * may be minimal (malaise/jaundice) to severe with compromise to multiple organ systems * anorexia, N/V, low grade fever, dark urine, clay colored stool, jaundice, acute liver failure * **AST/ALT 400-4000**

Answer 5

* Interferon * Lamivudine * Adefovir

Answer 6

* Interferon * Ribavirin

Answer 7

* Cellular immune response against self-antigens in the liver * Diagnosis confirmed with clinical findings, lab testing and histologic evaluation * No curative intervention * Goal is to induce remission with corticosteroids and immunosuppressive drugs or liver transplantation

Answer 8

Etiology * Chronic, progressive parenchymal damage leads to scarring and nodular formation Signs and Symptoms * Fatigue/Malaise * Jaundice * Anorexia/weakness/N/V * Spider angiomata * Hypoalbuminemia * Ascites/hepatomegaly * Coagulation disorders * Endocrine disorders * Hepatic encephalopathy * Gastroesophageal varices * Hyperdynamic circulation * Hepatorenal Syndrome

Answer 9

1. Hep. artery gives * 25% flow and 50% oxygen 2. Portal vein gives * 75% flow and 50% oxygen

Answer 10

1. volume status 2. RSI 3. Protein binding 4. ETOH on board? (lowers anesthetic requirements) 5. Cardiomyopathy 6. Consider vitamin K, FFP, Platelets 7. Administer glucose solutions

Answer 11

**Increased post-op morbidity** 1. Liver dysfunction/failure = #1 cause of death post-op 2. Pneumonia 3. Bleeding 4. Sepsis 5. Poor wound healing 6. DTs 7. Electrolyte disturbance 8. Renal failure

Answer 12

* **6-8** hours of ETOH withdrawal pt may become **tremulous** * **24** hours **hallucinations**, grand mal **seizures** may occur * **DTs** within **72** hours Treat with **benzos**

Answer 13

* **Metabolic disorder** that results from deficiency of specific enzyme in the heme synthetic pathway * deficiency of aminolevulinic acid (ALA) * Results in overproduction of porphyrins * Accumulation of intermediate forms of porphyrin at the site of enzyme blocked * Any increase in heme requirements results in accumulation of pathway intermediates * **Porphyrins** essential for physiologic functions * Oxygen transport and storage * Heme most important porphyrin * Bound to proteins * Production regulated by aminolevulinic acid (ALA) synthetase * Controlled by endogenous concentration of heme * Any metabolism needs that rely on the cytochrome P - 450 isoenzymes induce ALA synthetase resulting in increased intermediates

Answer 14

1. **Hematin 3-4mg/kg** (drug of choice) 2. Remove triggering agents 3. Hydration 4. Carbohydrates (b/c a trigger *is* fasting) 5. Treat pain and N/V 6. Beta blockers for HTN & tachycardia 7. Benzodiazepines for seizures 8. Fluid and electrolyte balance (10% glucose saline infusions) (also somatostatin, plasmapheresis)

Answer 15

Enzyme inducing drugs 1. Drugs that have an **Allyl group** →barbs 2. Drugs with a **Steroid** structure * Pentathol, thiamylal, methohexital, **etomidate** Hormonal fluctuations (everything we induce!) 1. fasting 2. dehydration 3. stress 4. infection

Answer 16

1. **Avoid known triggers** * minimize use of multiple drugs * Multiple enzyme inducing agents more dangerous than exposure to any one drug 2. **Minimize stress** 3. Ensure proper **hydration & carbs** * use glucose solution * Fluid and electrolyte balance * 10% glucose saline infusion 4. Give **anxiolytics** 5. Treat **pain/N/V** * BB for HTN and tachycardia * Benzodiazepines for seizures 6. **Cimetidine** * decreases heme consumption and inhibits ALA synthetase (good) 7. Hematin 3-4 mg/kg IV; Somatostatin; plasmapheresis

Answer 17

* Bilirubin * Aminotranferases * Alkaline Phosphatase * INR * Albumin

Answer 18

**Degradation product of hemoglobin and myoglobin** * **Unconjugated** is formed in the **periphery**→transported to **liver** via **albumin**→**conjugated** into **water** **soluble** compounds (unable to cross membranes)→**eliminated** from body _Increased ***UNconjugated*** bilirubin_ * Increased bilirubin **production** (hemolysis, skeletal muscle breakdown) * Decreased Hepatic **uptake** (low albumin stores) * Decreased **conjugation** _Increased ***Conjugated*** Bilirubin:_ * decreased canicular **transport** of bilirubin (billiary tract problem) * Acute/chronic **hepatocellular** **dysfunction** * **Obstruction** of bile ducts

Answer 19

* Lacks liver specificity → found throughout the body * **Cholestatic disorders** * ****increased levels may indicate damage of hepatic membranes from **bile salt** * **5'NT =** most specific to billiary damage

Answer 20

* Strong **correlation** of deteriorating hepatic function * Used in Child-Pough score * Incicates impairment of hepatic synthesis of **coagulation** **factors** and **Vitamin K** * Tests **2, 7, 9, 10** and proteins **C** and **S**

Answer 21

* **MOST** abundant plasma protein (only made in liver) * Synthesized by **hepatocytes** * _If levels are **decreased** may mean:_ * Protein manutrition * Loss of protein →nephrotic syndrome * severe reduction in synthesis from liver (acute liver failure will have high levels of albmin → albumin half life = 21 days )

Answer 22

* Etiology: * Gallbladder or biliary tract stone * Risk factors 1. Women 2. fair skinned 3. increased age 4. obesity or rapid weight loss 5. pregnancy * SXS: 1. N/V 2. **fever** 3. abdominal pain 4. **RUQ** tenderness radiates to back 5. intense pain 6. **dark urine** 7. **scleral icterus** * Treatment: * Surgery when condition has stabilized * Laparoscopic (5% convert to open) * ERCP (endoscopic retrograde chol-angio-pancreato-graphy)

Answer 23

* Insufflation of abdominal cavity (pneumoperitoneum) → increased intraabdominal pressure leading to: 1. Inadequate ventilation 2. Decreased venous return → decreased CO and increased MAP and SVR 3. Bradycardia due to peritoneal stretching * Increased MAP and SVR over several minutes restores CO * due to increased abdominal pressure * neurohumoral response and * absorbed CO2 * Risk for vascular injury and acute blood loss

Answer 24

1. Pre-Induction/Induction * _{Consider volume and electrolyte replacement} * _{RSI with cricoid pressure/cuffed ETT} 2. Watch PIP/MV and adjust ventilation accordingly 3. Reverse Trendelenburg aids surgical access and may improve ventilation 4. Support BP and HR 5. NG/OG tube 6. Avoid nitrous oxide 7. Judicious use of opioids * _{Opioids may cause Sphincter of Oddi spasm (morphine)} * * _{Antagonize spasm with IV Glucagon/Naloxone/Nitroglycerin}

Answer 25

Types: * Acute has 5 types - HAV, HBV, HCV, HDV, HEV * A most common in the world (50%) * C most common blood borne infection in US * D can only infect if the pt already has B * E for enteric transmission in Asia, Africa, Central America * Herpes simplex virus/ cytomegalovirus/ Epstein-Barr Diagnosis * Requires serologic testing or biopsy for definitive diagnosis Treatment * Treatment of acute viral hepatitis is symptomatic * good nutrition * avoid ETOH * avoid overexertion Complications * Development of cirrhosis and primary hepatocellular carcinoma associated with chronic HBV/HCV infection

Answer 26

Etiology * Cellular immune response against self-antigens in the liver Diagnosis * confirmed with: * clinical findings * lab testing * histologic evaluation Treatment * No curative intervention * Goal is to induce remission with corticosteroids and immunosuppressive drugs or liver transplantation

Answer 27

Etiology: * Analgesics, anticonvulsants, antibiotics, antihypertensives and many others * APAP exhausts glutathione stores leading to inability to conjugate substances * N-acetylcysteine within 8 hours Diagnosis * Sxs Resemble acute viral hepatitis so prompt diagnosis imperative treatment: * Removal of offending agent

Answer 28

Etiology: * Trifluoroacetyl halide metabolites from VA metabolism covalently bond with microsomal proteins on hepatocytes - changing them from “self” to “nonself” * IgG antibody mediated * All volatile anesthetics, except Sevoflurane, can elicit immune-mediated hepatitis * Halothane most common culprit due to high degree of liver metabolism * sensitized individuals may show cross-reactivity with other volatile anesthetics (except SEVO) * 1-10,000-30,000 Anesthetic management: * TIVA or Sevo great options

Answer 29

Child-Pugh Score * Tool used specifically to predict surgical mortality with cirrhosis * Assesses: 1. _{Total bilirubin} 2. _{serum albumin level} 3. _INR 4. _ascites 5. _{hepatic encephalopathy} * Class A= 10% mortality rate in intraabdominal surgery * Class B= 30% mortality * Class c= 80% mortality * A/B with preoperative optimization ok for surgery * class C surgery should be delayed (unless getting liver transplant)

Answer 30

_{*I appologize in advance for this long one*} * Preoperative Optimization! * Improve diet with protein and caloric intake * Blood glucose control pre/intra/post op (infusions with glucose?) * Aldosterone antagonist * Electrolyte and fluid status! * Encephalopathy * RSI * Judicious use of sedatives and induction agents * Ascites * RSI * Mechanical ventilation - behaving like a restrictive disease * PFTs * Pulmonary artery pressures * Fluid status - large removal of ascities w/out replacement with 7-8 g Albumin can lead to CV collapse * Esophageal Varices * no esophageal temp probe * no NG/OG tube * Bleeding? * RSI * Octreotide (50mcg/hr) * Vasopressin (20 U over 5 min) * Renal Impairment * Euvolemia * Monitor and correct for acid-base and electrolyte imbalances * Hyperdynamic Circulation * Decreased SVR mostly compensated with increased CO * Hypoalbumemia = edema * Cardiomyopathy * Avoid myocardial depressants * Invasive monitors, intravascular fluid replacement and vasopressors (phenylephrine/NE/Vasopressin) * Impaired response to catecholamines * Will see a limited response to increased dose requirements * Coagulopathy * T/C * Vitamin K non emergently * FFP, Cryoprecipitate, platelets * Only factors NOT produced by the liver are factors III, IV, XII * PRBCs * Impaired ability to handle citrate loads * Ionized calcium monitoring and calcium administration * Pharmacokinetics * Albumin * Decreased protein binding and increased VD * Decreased clearance * Example: larger initial dose of NDMR to compromise for the increased VD but decreased subsequent dosing due to decreased clearance * Caution with drugs dependent on liver clearance (cisatra/atra/miv great options) and drugs toxic to liver * Maintain liver blood flow * Hepatic artery 25% blood flow with 50% oxygen delivery * Portal vein 75% blood flow with 50% oxygen delivery * Intravenous anesthetics maintain hepatic blood flow if arterial blood pressure maintained * All inhalational agents maintain hepatic blood flow except halothane * Avoid SNS stimulation * give pain meds * prevent N/V * use lidocaine

Answer 31

* Chronic ETOH causes enzyme induction * increased anesthetic needs * Acute ETOH decreases anesthetic needs * due to ADDITIVE effects * Acute intoxicated * RSI * Heavy ETOH can lead to acute hepatitis

Answer 32

Signs & Symptoms * Increased SNS- catecholamine release * Agitation * Tachycardia * Delirium tremors (48-72 hours post ETOH)à medical emergency * Hallucinations * Diaphoresis * Cardiac dysrhythmias * Hemodynamic instability * Grand mal seizures and hypoglycemia Treatment * Benzodiazepine * Beta antagonist (propranolol or esmolol) * Airway protection * Correct fluid/electrolyte and metabolic disturbances * DT’s mortality rate is 10% due to hemodynamic instability, cardiac dysrhythmias and seizures

Answer 33

1. Severe abdominal pain/N/V due to autonomic neuropathy * think RSI for induction 2. ANS instability 3. Electrolyte imbalances (Na, K, Mg) 4. Skeletal muscle weakness- respiratory failure 5. Cardiovascular instability resulting in Hypertension and tachycardia (less likely hypotension) 6. Seizures

Answer 34

1. Pre-op prep * Identify and avoid triggers (www.drugs-porphyria.com) * Assess: * skeletal and CN function * Cardiac - HTN, tachycardia 2. Intra-op * Minimize multiple drug exposure * Fluid/electrolyte management * Anticipate post-op ventilation * Minimize stress of preop fasting glucose-saline infusion 3. Preop meds * Anxiolytics, aspiration prophylaxis * Cimetidine inhibits ALA synthetase activity and decreases heme consumption

Answer 35

Regional * No absolute contraindications * Pre anesthetic neuro eval * ANS blockade may lead to cardiovascular instability especially with hypovolemia * **Avoid in acute exacerbation** General * Use short acting agents * Monitors! * they may need an a-line * Induction with propofol or ketamine * Maintenance with N20, inhaled anesthetics, opioids and NDMR * Cardiopulmonary bypass is a stressor

Answer 36

1. Opioids 2. Propofol 3. Ketamine 4. ASA/APAP 5. PCN 6. Glucocorticoids 7. Insulin 8. Atropine/Glycopyrrolate 9. Neostigmine 10. Locals 11. Most cardiovascular drugs 12. Inhalational agents 13. NDMR

Answer 37

SEND Phil BAK 1. **S**ulfonamide antibiotics 2. **E**tomidate 3. **N**ifedipine 4. **D**iazepam 5. **P**henacetin/Phenobarb 6. **B**arbiturates 7. **A**lcohol 8. **K**etorolac

Liver reduced I Flashcards

(61 cards)