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673 Advanced Anesthesia Principles > Week 4 Hepatobiliary & Pancreas > Flashcards

Week 4 Hepatobiliary & Pancreas Flashcards

(94 cards)

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1
Q

What amount and percent of blood flow is directed towards the liver?

A

100mL/100g/min ~ 1500mL/min

or

25-30%

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2
Q

Hepatic Oxygenation comes from what percent of what vessels?

A

50% Hepatic Artery

50% Portal Vein

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3
Q

Hepatic perfusions comes from what percent of what vessels?

A

25-30% Hepatic Artery

70-75% Portal Vein

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4
Q

Normal hepatic portal venous pressure?

A

7-10mmHg

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5
Q

What is considered portal HTN?

A

Sustained portal pressure >10mmHg

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6
Q

Rate of drug metabolism equation

A

Rate = Q (Drug in concentration - Drug out concentration)

Q = blood flow

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7
Q

Where does the SNS innervation of the liver come from?

A

Celiac plexus (T3-T11)

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8
Q

Where does PNS innervation for the liver come from?

A

R & L Vagus n.

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9
Q

What does a Kupffer-Browicz cell do?

A

Is the thing that protects from bacteria that originates in the gut

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10
Q

In order, which zones of the liver receive the most oxygentation?

A

Zone 1 > Zone 2 > Zone 3

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11
Q

Which zone of the liver is the most susceptible to ischemia?

A

Zone Tres

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12
Q

What are some of the primary functions of the hepatic system?

4

A
  • Carbohydrate & glucose metabolism/homeostasis
  • Protein synthesis/metabolism
  • Coagulation
  • Drug metabolism
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13
Q

What is the principle action of phase I reactions?

A

Hepatocytes modify drugs by Hydrolysis, Oxidation, Methylation, & Reduction

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14
Q

What is the principle enzyme of phase I reactions? What change to it can alter drug metabolism either increase or decrease?

A

CYP450
* Deficiency/Overabundance

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15
Q

What is the principle action of Phase II reactions?

A

Conjugation via glucoronidation, sulfation & acetylation

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16
Q

Which metabolic pathway is important for several anesthetics?

A

Acetylation of the phase II pathway

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17
Q

What are some inducers of CYP450?

4

A
  • Phenytoin
  • Phenobarbital
  • Rifampin
  • Etoh
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18
Q

What are some inhibitors of CYP450?

A
  • Grapefruit juice
  • Cimetidine
  • Ciprofloxacin
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19
Q

What effect(s) does chronic liver disease have on drug metabolism?

4

A

Prolonged DoA
* decrease Albumin
* decrease # of Enzymes
* decrease Hepatic blood flow

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20
Q

What is the normal blood volume of the liver?

A

~450mL or 10% of total blood volume

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21
Q

A hemorrhaging, vasoconstricted, hypovolemic pt’s liver may have a blood volume as low as?

A

300mL

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22
Q

In situations with CHF, Pulm. HTN, & Hypervolemia, how much blood can the Liver hold onto?

A

1L

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23
Q

How much glycogen can be stored in the liver? Compared to how much is consumed per day?

A

70g of Glycogen

150mg/day consumed

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24
Q

What is the toxic byproduct of protein deamination?

A

Ammonia

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25
How is Ammonia eliminated? Chemical equation?
Formed into urea CO2 + (NH3)^2 = Urea
26
The Liver forms all plasma proteins except?
Immunoglobulins
27
Negatively charged plasma protein that binds acidic drugs?
Albumin
28
Positively charged plasma protein that binds basic drugs?
Alpha 1 Antitrypsin
29
Besides floating around in the blood like a bum, what else does Alpha 1 Antitrypsin do?
Protects lungs from neutrophil elastase
30
How is bilirubin metabolized/eliminated?
Conjugated in the liver increase, increase water-solubility, increase Bile
31
What is increase LFTs indicative of?
Liver injury, but not necessarily obstruction
32
If AST & ALT both increase, what does this indicate?
Hepatitis or Hepatic dysfunction
33
If the AST/ALT ratio is 2-4, what does this indicate?
Alcoholic Liver disease
34
Where is Alanine Aminotransferase (ALT) found?
Highly specific to the Liver
35
Where is Aspartate aminostransferase (AST) found?
Found in extrahepatic tissue
36
What is the negative of Alkaline phosphatase?
Lacks specificity as a diagnostic for liver disease
37
What may an increase Alkaline phosphatase indicate?
Post-hepatic biliary obstruction
38
Which procedure may be indicated for an increase Alkaline phosphatase?
Endoscopic retrograde cholangiopancreatography (ERCP)
39
Which coagulation test may be specific for liver dysfunction? Why?
PT/INR Vitamin K dependent factors
40
In the case of elevated INR, what is your preoperative managment
FFP
41
What is the most reliable indicator of hepatic synthesis
albumin levels (normal 3.5-4.5)
42
Volatile agents capable of producing hepatits
* Halothane * Enflurane * Isoflurane * Desflurane
43
Respiratory changes in cirrhosis
* hyperventilation --> respiratory akalolsis * right to left shunting * decreased FRC * restrictive ventilation pattern (pleural effusions)
44
What is the number one cause of chronic hepatitis in the US?
ETOH
45
What is the hallmark sign of End Stage Liver disease?
Portal HTN
46
How does chronic hepatitis cause cirrhosis?
Parenchymal damage -> replace liver tissue w/ scar tissue
47
Most common chronic bloodborne infection in the United States?
Hep C
48
Early S/s of Cirrhosis? | 3
* RUQ pain * GI disturbances * Spleno/hepatomegaly
49
Late S/S of cirrhosis? | 6
* Fatigue * Jaundice * Spider angioma * Gynecomastia * Ascites * Small balls
50
Pathogenesis of Ascites?
* Portal HTN * Hypoalbuminemia * Na/H2O retention
51
Conditions worsening hepatic encephalopthy
* **GI bleed** * increased protein intake (will be metabolized to ammnoia) * hypokalemic acidosis
52
How does portal HTN cause esophageal varices?
The lower 1/3 of esophagus drains to the gastric & Portal veins
53
Major cause of mortality in cirrhosis/Etoh abuse pts?
Gastroesophageal varices
54
Anesthetic implications for TIPS procedure | 5
* GETA * Avoid NG/OG * 2 - Large bore IVs * +/- CVL/AL * Type & Cross
55
MAC requirements w/ Acute ETOH intoxication?
decrease MAC
56
MAC requirements w/ chonic ETOH abuse (but not currently intoxicated)?
increase MAC
57
Why is an acutely intoxicated pt at risk for aspiration?
* decrease Gastric emptying * decrease LES tone * decrease LOC
58
When does Delirium Tremens occur?
48-72 hrs post-drink
59
S/S Delirium Tremens | 5
* Tremors * Hallucinations * Hyperpyrexia * Dysrhythmias * Grand mal seizures
60
What medications might be used for tx of Portal HTN induced Gastroesophageal varices? | 4
* Beta-blockers (Propanolol, nadolol) * Octreotide * Statins (Simvastatin) * Nitrates (Isosorbide mononitrate)
61
Hemodynamic/cardiac considerations for Cirrhotic pts? | 5
* decrease SVR * decrease Viscosity * increase CVP * AV shunting * **increase CO**
62
Pts w/ ascites are at risk for what respiratory condtion, pre & post-operatively? Why?
Atelectasis * decrease FRC * decrease Vt
63
Cirrhotic pts have an increased volume of distribution due to what physiological change?
Alterations in protein binding
64
What pharmacokinetic change do Cirrhotic pts and babies have in common?
Require higher NDNMB dose, & less maitenance dosing
65
Succinylcholine may have a prolonged DoA in Cirrhotic pts due to a decrease in what enzyme?
Pseudocholinesterase
66
Which NDNMB is best for hepatic/renal disease and why?
Cisatracurium/Atracurium * Organ independent metabolism
67
What effect do volatile anesthetics have on hepatic system during surgery?
* decrease in Systemic BP * decrease Hepatic blood flow * N2O further decrease HBF
68
How much & how long does Hepatic blood flow change during volatile agent administration?
* 35-42% decrease HBF on induction * Sustained decrease for 30 min
69
Which pain medication should be avoided in liver patients and why?
Morphine * Metabolized by glucuronditation * Leads to hepatic encephalopathy
70
α cells of the islet of langerhans make up what % of total & what do they secrete?
* 25% of islet cells * Glucagon
71
β cells of the islet of langerhans make up what % of total & what do they secrete?
* 60-70% of islet cells * Insulin * Amylin (inhibits insulin)
72
δ cells of the islet of langerhans make up what % of total & what do they secrete?
* 10% of islet cells * Somatostatin (inhibits GH)
73
What do Pancreatic polypeptide cells of the islet of langerhans secrete?
They inhibit exocrine secretion
74
What is the body's main antiketogenic hormone?
Insulin
75
Etiology of Acute Pancreatitis? | 9
* **ETOH abuse** * **Biliary tract disease** * Trauma (Direct/indirect) * Ulcerative penetration from adjacent structures * Infectious processes * Drugs * Autoimmune * Metabolic disorders * Surgical manipulation
76
How often does HoTN occur in Acute Pancreatitis?
In 40-50% of pts
77
Why does HoTN occur in Acute Pancreatitis?
Hypovolemia 2/2 loss of plasma proteins in the retroperitoneal space
78
What is the hallmark sign of Acute Pancreatitis
increase Serum amylase concentration (will be normal in chronic pancreatitis)
79
When is an NG indicated for Acute Pancreatitis?
Only indicated w/ co-existing ileus
80
What is Chronic pancreatitis?
Permanent & irreversible damage to Pancreas
81
Classic triad of Chronic Pancreatitis?
* Steatorrhea * Pancreatic calcification * DM
82
Strategies to limit the amount of blood loss during a liver surgery?
* Low CVP (< 5 mmHg) * Hepatic Vascular occlusion (pringle) * TXA and Factor VIIa
83
What does a TIPS procedure do, and what is it meant to tx?
* Creates shunt from Portal vein -> Hepatic vein * Tx Portal HTN (HVPG should be < 12 after)
84
How to keep CVP < 5 in liver surgery | 6
* IVF 1 mg/kg/hr * vasopressors for SBP > 90 and UO > 25 mL/hr * vasodilators (NTG, morphine), and diuretics * milrinone * reverse T-berg * epidural
85
S/S of Portal HTN? | 3
* Ascites * Hepato/splenomegaly * Peripheral edema
86
Anesthetic Plan for a pt undergoing a whipple procedure | 4
* Aspiration precautions (NG tube) * Hypoglycemic precautions * Fluid Resuscitation (Hypovolemic/HoTN) * Correct electrolyte disorders
87
What causes coagulopathy in Liver pts?
* Impaired synthesis of clotting factors * Thrombocytopenia
88
What causes impaired synthesis of clotting factors
Decreased synthesis of all clotting factors (except III, IV, & vWF)
89
How is the liver involved in thrombocytopenia?
* Folate deficiency (Poor nutrition/ETOH) * Platelets sequestered into enlarged spleen 2/2 Portal HTN (90% of them)
90
CV Δs in pts w/ ESLD/Portal HTN | 9
* increase CO * decrease SVR * decrease ABP * increase circulating volume with relative hypovolemia * AV shunting * Portal HTN (duh) * Esophageal varicies * Cardiomyopathy * CHF
91
Tx for Variceal bleeding? | 4
* Tx underlying disease * Correct coagulopathy * Drugs * EGD/Banding/Blakemore tube
92
S/s of Acute Pancreatitis | 5
* Excruciating mid-epigastric pain * N/V * Abdominal distension w/ ileus * **HoTN** * **hallmark: elevated serum amylase**
93
Manifestations of Hepatorenal syndrome? | 5
* Oliguria * Na+ retention * Azotemia * Ascities * MODs
94
How to tx Hepatorenal syndrome | 5
* D/c nephrotoxic agents (ACEis, ARBs, NSAIDs, Diuretics) * Abx for infections * IV albumin to maintain CVP 10-15 * Vasopressor therapy (Midodrine/octreotide/NE) * liver transplant

673 Advanced Anesthesia Principles (4 decks)

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