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Liver Kidney + Transplant Anesthesia > Liver + Transplant Anesthesia > Flashcards

Liver + Transplant Anesthesia Flashcards

1
Q

What is the functional unit of the liver?

A

Hepatic lobule or acinus

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2
Q

What does the hepatic artery branch from & how much oxygenated blood is delivered?

A

-Aorta
-Delivers 400-500 mL/min O2 blood

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3
Q

How much blood is delivered to the liver (arterial + venous)

A

Hepatic artery & portal vein = 1.5 lpm

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4
Q

Hepatic artery pressure is __________ mmHg which is similar to the aorta

A

6-10 mmHg

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5
Q

The hepatic artery has what receptors & what properties?

A

-Alpha adrenergic = vasoconstricting

-Beta receptors = vasodilating

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6
Q

The portal vein has what receptors & properties?

A

Alpha adrenergic + Dopaminergic 1

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7
Q

How does glucagon affect the hepatic artery?

A

Dilates Hepatic Artery

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8
Q

How does angiotensin affect the hepatic artery & subsequently hepatic blood flow?

A

Hepatic artery constricts & decreases HBF

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9
Q

How does vasopressin affect intrahepatic portal vessels?

A

Dilates intrahepatic portal vessels

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10
Q

What happens when there is a decrease in portal vein flow?

A

Compensatory increase in hepatic artery flow

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11
Q

Describe the “internal liver blood blank” or reservoir function

A

Doesn’t last very long & doesn’t work very well under GA.

-Autotransfusion of 300-350mL of blood can be shifted into central venous circulation
-If CHF = can be up to 1L of blood in liver d/t increased CVP

-Low resistance sinusoids allows a lot of blood to flow through the PV w/ 10% of TBV in liver

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12
Q

Arterial Buffer Response

A

Regulates tone via local & intrinsic mechanisms that adjust arterial flow to compensate for changes in portal flow.
-AKA own system within a system which is why the liver can regenerate itself

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13
Q

What are the clotting factors synthesized by the liver?

A

1972 + 510

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14
Q

What undergoes metabolism in the liver

A

Carbs, lipids, proteins, hormones, bili, drugs

-Drugs = phase 1 & phase 2 reactions

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15
Q

What anesthetic drugs have a HIGH hepatic extraction ratio that is dependent on hepatic blood flow?

A

marcaine, ketamine, lidocaine, metoprolol

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16
Q

What anesthetic drugs have a LOW extraction ratio that is independent of liver blood flow?

A

ROC, thiopental, phenytoin

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17
Q

Shunts of the portal system do what to 1st pass metabolism

A

decreases first pass metabolism

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18
Q

Phase 1 reactions metabolize…

A

Anesthetic drugs

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19
Q

Hypoalbuminemia & drugs

A

Increased free drug w/ increased Vd.

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20
Q

Anesthetic agents affect on liver

A

Decrease HBF & hepatocellular function

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21
Q

What kind of drugs does albumin bind

A

Acidic drugs

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22
Q

MELD score uses what 4 categories for grading/

A

INR, Creatinine, Bilirubin, Sodium

“I create bull-shit”

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23
Q

A MELD score <11 means

A

low postop mortality w/ an acceptable surgical risk

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24
Q

MELD score >20 means

A

Elective surgery delayed until after transplantation

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25
Q

Causes of liver cirrhosis

A

viral, autoimmune, toxic, metabolic, biliary, vascular, genetic, iatrogenic

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26
Q

Which drug works wonders for acute intoxication/

A

Dexmedetomidine

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27
Q

What labs are critical to look at with liver disease because these will change your anesthetic

A

Albumin & PT

28
Q

Cirrhosis patients and LES

A

Incompetent LES with abdominal distention. PPV >20 cmH2O can cause seriously problems

-Aspiration prophylaxis. Mayka gives Famotidine, Zofran, Dexamethasone upfront

29
Q

What visual test should be done prior to liver transplant

A

EGD

30
Q

What do avoid with cirrhosis management

A

Hypotension, hypocarbia, PPV >20 if possible

31
Q

What invasive monitorning device should be considered in cirrhosis

A

CP or PA pressures for PAH

32
Q

How does fentanyl effect the elderly liver

A

Decreased clearance d/t HBF decrease

33
Q

How does fentanyl effect HBF

A

No change or increase in HBF

34
Q

How does sufenta effect HBF

A

Decreases hepatic blood flow
-Extensive hepatic extraction = sensitive to changes in HBF

35
Q

How does Remi effect HBF

A

Not altered in hepatic failure because it is metabolized by nonspecific plasma & tissue esterases

36
Q

Meperidine & hepatic metabolism

A

90% hepatic metabolism
Prolonged elimination with cirrhosis/liver failure

37
Q

Ester local anesthetic metabolism & liver disease

A

Slowed with liver disease or increased BUN

38
Q

Propofol & liver

A

Decreases P450 activity
-Boluses decrease HBF by 40%
- Undergoes rapid hepatic metabolism

39
Q

Etomidate & liver

A

CAUTION with low albumin levels
-Good for cardiac patients
-Decreases HBF & inhibits P450 activity
-Highly protein bound

40
Q

Ketamine & liver

A

Causes enzyme induction w/ repeated exposure
-P450 metabolism

41
Q

Succinylcholine & liver

A

-Liver disease must be severe before a decrease in plasma cholinesterase production & sufficient to prolong effect
-Pseudocholinesterase t1/2 = 8-16hr

42
Q

Vecuronium & liver

A

-40-75% biliary excretion
-Prolonged excretion w/ cirrhosis

43
Q

Rocuronium & liver

A

Prolonged excretion w/ cirrhosis

44
Q

Important to verify/check when paralyzing a patient with possible liver disease/cirrhosis

A

Check twitches after SUX & before ROC to verify no pseudocholinesterase deficiency

45
Q

What volatile anesthetic(s) cause a minimal dose-dependent decrease in hepatic artery & portal vein blood flow?

A

ISO & SEVO

46
Q

What volatile anesthetic(s) causes moderate dose-dependent decrease in hepatic artery & portal vein blood flow

A

DES

47
Q

Preoperative consideration with liver/liver transplant patients

A

-GA = RSI d/t ascities & increase IAP
-Induction etomidate?
-SUX vs ROC
-1/2 MAC
-Narcs
-A-line + CVP + 2 large boare IV
-Rapid infusion system

48
Q

Preanhepatic phase

A

Stage 1
-Incision until access to liver vessels obtained

49
Q

Issues with preanhepatic phase

A

-Sequestration of blood + volume status
-Citrate intoxification causing hypocalcemia
-Potassium < 4 d/t diuresis, insulin, glucose
-Temperature =ice cold liver on field, warm ischemia time
-Bypass flow

50
Q

MAP goal during preanhepatic phase. What drugs to maintain?

A

NE or vasopressin to keep mean BP >60 mmHg

51
Q

Cardiac output goal during preanhepatic phase. What drugs to maintain?

A

Dopamine or EPI to keep CO >5 lmp

52
Q

Heme goals during preanhepatic phase

A

Hgb >7 g/dL
PLT >40K
MA (TEG) >45
Fibrinogen > 100 mg/dL

53
Q

Mannitol dose prior to anticipating clamping during preanhepatic phase

A

0.5g/kg over 1 hour prior to anticipating clamping

54
Q

3 things to do just prior to clamping during preanhepatic phase

A

-IV heparin if TEG is normal or hypercoagulable
-Increase CVP to 10cmH2O w/ crystals
-25% albumin if severely low albumin

55
Q

Stage II/Anhepatic Phase is when …

A

Liver vessels clamped or hepatectomy until reperfusion

56
Q

Stage II/Anhepatic phase issues

A

-Sequestraion of blood & hypotension d/t vena cava cross clamp (50% decrease in venous return)
-***Citrate intoxification = hypocalcemia –> give amps of calcium when hypoperfusing
-K below 4 from diuresis, insulin, glucose
-Ice cold liver on field, warm ischemia time
-Bypass flow

57
Q

V-V bypass during Anhepatic Phase

A

-Cannula in portal vein
-Iliac vein drain to heparin bonded pump
-Return by axillary or jugular bypass

**Benefit able to replace clamps in stage III if needed

58
Q

Neohepatic phase/Stage III

A

-Reperfusion of graft to end of case
***Greatest hemodynamic changes seen

59
Q

Issues seen in neohepatic phase

A

-Acute hyperK
-Reperfusion syndrome
-PE & or edema
-Coagulation
-Anastamosis leak/injury of IVC
-Assessing quality of donor organ

60
Q

Reperfusion syndrome

A

-Brady, HoTN, Decreased CO
-Release of cytokines, cold acidosis, products of ischemic metabolism
-Clotting system activation
-Lysis occurs: TXA

**Tx –> EPI & defibrillator available
-HCO3 & CaCl to conteract hyperkalemia

61
Q

TEG R-time

A

prolonged d/t heparin, thrombocytopenia, lysis

*Tx = FFP

62
Q

TEG MA

A

Function of PLTs

*Tx = PLT

63
Q

TEG angle <20 degrees

A

Thrombocytopenia, PLT dysfunction, decreased thrombin, decreased clotting factors

*Tx = CRYO or PLT

64
Q

Fibrinolysis on TEG

A

Not often seen.

*Tx = Amicar 250-500 mg IV

65
Q

3 Channel on TEG

A

1- Natural
2- Protamine if heparin effect is removed
3- Amicar how blood would clot if lysis stopped

**If amicar channel is “better” than the other 2 = Lysis

66
Q

When treating HTN during liver transplant. What antihypertensives do you want to avoid?

A

Avoid long acting agents

Liver Kidney + Transplant Anesthesia (2 decks)

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